Correct Coding of Custom-Fit Codes Without an OTS Counterpart
What You Need to Know
While most custom-fit codes have a parallel off-the-shelf code, some do not. As we have written about before, custom-fit codes require more than minimal self-adjustment by a qualified individual at the time of delivery. Sometimes, however, a device described by a custom-fit code that does not have an OTS counterpart gets fit with little to no adjustment needed. In this situation, your records would be missing documentation showing more than minimal self-adjustment by a qualified individual at the time of delivery, so using the applicable custom-fit code would be inappropriate.
Citing "multiple recent inquiries to the PDAC and DME MACs," these contractors issued a joint revised publication last week spelling out what to do in this scenario. When billing a device that has only a custom-fit code and no parallel OTS code, you must use one of the following miscellaneous codes: L1499 (spinal orthoses), L2999 (lower extremity orthoses), L3999 (upper limb orthoses).
What this Means for You
Your staff should know the specific custom-fit orthotic codes that do not have an OTS equivalent. If you provide an item to a patient that requires only minimal self-adjustment but is described by a custom-fit code, you must use a miscellaneous code when billing it.
Below is a comprehensive list of the custom-fit codes that do not have a parallel OTS code:
L0113, L0140, L0150, L0180, L0190, L0200, L0458, L0460, L0462, L0464, L0470, L0472, L0488, L0490, L0491, L0492, L0635, L0720, L0810, L0820, L0830, L1001, L1005, L1600, L1610, L1620, L1650, L1660, L1686, L1690, L1831, L1910, L1930, L1971, L2035, L2112, L2114, L2116, L2132, L2134, L2136, L3931, L3960, L3962, L3980, L3981, L3982, L3984.
Even if you are already familiar with this general guidance, please make sure to review the above list of codes carefully, as two codes (L1932 and L1951) were removed from it and L0720 was added.
To see the complete joint guidance article from the PDAC and DME MACs, click here.