In the wake of the Operation Brace Yourself fraud scheme, suppliers should expect increased Medicare scrutiny of claims for prefabricated braces, both off-the-shelf (OTS) and custom-fitted. As such, suppliers need to understand Medicare guidelines to support billing practices and protect their business from overpayments and recoveries.
One Brace, Two Codes?
Both OTS and custom-fitted braces are prefabricated, and both items can require assembly. Neither assembly, installation of add-on components, nor the use of basic materials to prepare the item qualify a brace as custom-fitted. When a brace does not fit a patient out of the box, the degree of expertise and modification required to achieve proper fit determines its status as OTS or custom-fitted. That is why the PDAC assigns multiple HCPCS to the same makes and models of prefabricated braces.
Presume It’s Off-the-Shelf
Braces are classified as OTS when:
What Makes Custom-Fitted Braces Unique?
The same brace may be classified as custom-fitted when:
Experts include:
Recently the MACs opined that ABC certified orthotic fitters are not equivalent to certified orthotists. Therefore, certified fitters are not eligible to provide custom-fitted orthotics.
Custom-Fitted Documentation
Medicare reviewers rely solely on available documentation to support the conclusion a brace would not fit properly without significant adjustments. MiraVista recommends suppliers maintain detailed records when billing for custom-fitted orthotics. Suppliers should:
Using the Correct Code
The following table lists corresponding custom-fitted and OTS HCPCS. Because some of the custom-fitted codes do not have a corresponding OTS code, the MACs instruct suppliers to use equivalent miscellaneous HCPCS with a narrative that explains the supplier is providing an OTS brace.
One Brace, Two Codes?
Both OTS and custom-fitted braces are prefabricated, and both items can require assembly. Neither assembly, installation of add-on components, nor the use of basic materials to prepare the item qualify a brace as custom-fitted. When a brace does not fit a patient out of the box, the degree of expertise and modification required to achieve proper fit determines its status as OTS or custom-fitted. That is why the PDAC assigns multiple HCPCS to the same makes and models of prefabricated braces.
Presume It’s Off-the-Shelf
Braces are classified as OTS when:
- Minimal modifications are needed to achieve a good fit to the beneficiary.
- Fitting and adjustments do not necessitate the expertise of a certified orthotist or an individual who has specialized training to fit the item to the beneficiary. Non-expert modifications include assembly, strap and closure adjustments, bending, and trimming for final fit and comfort.
What Makes Custom-Fitted Braces Unique?
The same brace may be classified as custom-fitted when:
- Extensive modifications are necessary to achieve a good fit to the beneficiary.
- The level of adjustments and modifications merit the expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses.
- Expert modifications substantially alter the brace to achieve an individualized fit and require extensive trimming, bending, molding (with or without heat), or other modifications that would exceed the abilities of an untrained individual.
Experts include:
- ABC or BOC certified orthotists.
- Individuals with documentation of specialized training for the proper fitting of orthotics (generally interpreted as physical or occupational therapists).
Recently the MACs opined that ABC certified orthotic fitters are not equivalent to certified orthotists. Therefore, certified fitters are not eligible to provide custom-fitted orthotics.
Custom-Fitted Documentation
Medicare reviewers rely solely on available documentation to support the conclusion a brace would not fit properly without significant adjustments. MiraVista recommends suppliers maintain detailed records when billing for custom-fitted orthotics. Suppliers should:
- Document unique beneficiary characteristics that merit substantial modifications (such as deformities, bulbous knees or ankles, unusual anatomical proportions, etc.).
- Maintain documentation on how the brace is modified to achieve a proper, individualized fit.
- Employ qualified staff, recognized by Medicare, to perform custom fitting adjustments before billing with custom-fitted HCPCS.
Using the Correct Code
The following table lists corresponding custom-fitted and OTS HCPCS. Because some of the custom-fitted codes do not have a corresponding OTS code, the MACs instruct suppliers to use equivalent miscellaneous HCPCS with a narrative that explains the supplier is providing an OTS brace.
Medicare currently reimburses OTS and custom-fitted codes assigned to the same brace at the same amount, but suppliers should expect pricing changes after several off-the-shelf HCPCS proceed through Round 2021 competitive bidding.
Above all, remember Medicare only covers braces that:
The LCDs outline specific coverage criteria, and policy articles indicate when select codes require specific diagnoses to support medical necessity.
SOURCES
https://cgsmedicare.com/jb/pubs/news/2019/07/cope13077.html
https://www.fbi.gov/news/stories/billion-dollar-medicare-fraud-bust-040919
https://www.abcop.org/Pages/Individual-Search.aspx
http://go.bocusa.org/
Above all, remember Medicare only covers braces that:
- Support a weak or deformed body member, or
- Restrict or eliminate motion in a diseased or injured part of the body.
The LCDs outline specific coverage criteria, and policy articles indicate when select codes require specific diagnoses to support medical necessity.
SOURCES
https://cgsmedicare.com/jb/pubs/news/2019/07/cope13077.html
https://www.fbi.gov/news/stories/billion-dollar-medicare-fraud-bust-040919
https://www.abcop.org/Pages/Individual-Search.aspx
http://go.bocusa.org/
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