New OTS Orthotic Codes

CMS approved two new HCPCS codes for a prefabricated off-the-shelf knee orthosis and hip orthosis to parallel current HCPCS codes L1820 and L1652, respectively. This article will summarize these new codes, including their reimbursement rates and effective date.

What You Need to Know

During the first biannual 2024 HCPCS coding cycle, Palmetto GBA submitted a request to the HCPCS coding committee to create parallel OTS codes for custom-fit codes L1820 and L1652. The committee approved the request and created codes L1821 and L1653 to describe an OTS version of each orthosis. CMS added these codes to the Q4 HCPCS file, and they can be used for billing orthoses delivered on or after October 1, 2024. CMS also determined the fee schedule amount for each new code, which is equivalent to the fee schedule for the respective custom-fit codes. Therefore, the reimbursement rates for L1821 and L1653 are equivalent to the reimbursement rates for L1820 and L1652, respectively. Lastly, the coding committee decided to modify the description of L1820 and L1652 to match other custom-fit codes with OTS parallel codes. The complete descriptions of all four codes are:

• L1821: Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf

• L1820: Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

• L1653: Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, off the shelf

• L1652: Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

What this Means for You

Currently, if you provide an L1820 or L1652 brace with "minimal self-adjustments," Medicare requires billing with miscellaneous code L2999 because these are custom-fit codes without an OTS equivalent. However, starting next month, OTS parallel HCPCS codes L1821 and L1653 will be valid and billable for any deliveries on or after October 1, 2024. This will eliminate the need to bill a miscellaneous code when delivering these braces without significant modifications. Along with providing education to your staff about these upcoming changes, make sure to update your EMR system to include the new HCPCS codes and their associated fee schedules.

For more information, review pages 43-45 of the HCPCS Application Summary for the 2024 first biannual coding cycle.