Medicare Coding for Adjustments, Repair or Replacement of Custom Fabricated or Off-The-Shelf (OTS) Orthoses
97760, 97763, L4002, L4210, L4205
These guidelines are used for general application. Providers are encouraged to consult with their regional DME MAC jurisdiction. The information provided below reflects information obtained from discussions with PDAC, Noridian and the Centers for Medicare and Medicaid Services. For non-Medicare/Medicaid billing, clinicians should carefully review each individual insurance contract, fee schedule and reimbursement prior to using any of these codes. Acceptance among private payers varies depending on the state, the plan and the carrier.
Adjustments to Custom Fabricated, Previously Fit, Prefabricated Orthoses
- 97760 Initial Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes. This code may be used to bill at the initial encounter for training the patient to use the orthosis. The HCPCS L code includes evaluation, fabrication and fitting. The L code does not include training that may be necessary for the orthosis to be effective. For example, training that may be necessary for a tenodesis orthosis to be effective. Documentation must support the use of both codes at the initial encounter.
- 97763 Subsequent Orthotic(s)/prosthetic(s) management and/or training, upper extremity(ies), lower extremity(ies), and/or trunk, subsequent orthotic(s)/prosthetic(s) encounter, each 15 minutes. 97763 should be used to describe any and all subsequent encounters for orthotics and/or prosthetics management and training services.
Examples include;
- Modification time for a custom fabricated or an off-the-shelf (OTS) orthosis due to tissue changes (example: adjustments to serial static or static progressive devices)
- Edema changes that warrant remolding or interruption in skin integrity/skin irritation such as sensitive or insensitive areas.
- It may also be used for an involved remolding of the orthosis (example: to reheat and reshape the orthosis to increase the extension of the wrist and fingers when serial orthosis fabrication is used to increase passive extension after a flexor tendon repair that is 6 weeks or more post-op)
Documentation must support the use of the code for an adjustment:
- Reason for the adjustment
- What was adjusted
- How much time was spent performing the adjustment
- If used repeatedly, documentation must adequately support the repeated use of this code
Documentation must include:
- A description of the patient’s condition (including applicable impairments and functional limitations) that necessitates an orthotic
- Any complicating factors
- The specific orthotic provided and the date issued
- A description of the skilled training provided
- Response of the patient to the orthotic
- The justification for a skilled qualified professional to train the patient
Note: A new physician’s order or certificate of medical necessity is not necessary.
Note: A modifier 52 would not be warranted according to AMA’s CPT assistant, February 2007 (Vol.17, issue 2) and December 2005.
Repair for Custom Fabricated Orthoses
Definition: To fix or mend a piece of DME in order to return the equipment to working condition after damage or wear. This service is covered under Medicare when necessary to make the equipment serviceable.
L4205: Labor for repair of orthotic device ea. Timed code = 15 minutes.
Documentation requirements:
- Proof of medical necessity – that the beneficiary still requires the item.
- Reason for the repair
- What was repaired and how was it repaired?
- How much time did the repair take?
Note: There may be local coverage determinations in some regions that limit how soon after the initial dispensing of the orthosis this code can be billed.
Note: A new physician’s order or certificate of medical necessity is not necessary.
Replacement of Parts
L4210: Repair of orthotic device: repair or replace minor parts. This code is used to bill for the components needed in the repair that do not have separate codes (screws, nuts, rivets, elastic, etc.).
Note: A new physician’s order or certificate of medical necessity is not necessary.
Documentation requirements:
- Proof of medical necessity – that the beneficiary still requires the item.
- Reason for the repair
- What was repaired and how was it repaired?
- How much time did the repair take?
- Include the cost of the replacement item(s)
Billing requirements: This code must be billed with the modifiers for side: RT, LT and the modifier RB: replacement of a part of DMEPOS furnished as part of a repair.
Note: In addition, the narrative portion on the electronic bill must describe the parts. For paper claims, a description must be attached to the claim.
L4002: Replacement straps: must be accompanied by a description in the narrative portion of the electronic billing as well as the chart as to the reason for replacement of the straps.
Note: A new physician’s order or certificate of medical necessity is not necessary
Orthotic Replacement
Replacement: substitute an item for another due to breakage, loss, theft or natural disaster. Replacements are covered for loss, theft (police report or patient signed statement must be in chart) or natural disaster.
Note: Orthoses that are worn out are not covered by Medicare.
Note: A new physician’s order and certificate of medical necessity is required as well as documentation regarding the circumstances necessitating the replacement.
Note: The orthosis should be billed with the RA modifier to indicate that it is a replacement.
Resources:
https://med.noridianmedicare.com/web/jddme/topics/modifiers/ra