Revision to the LSO/TLSO Policy Article


The Durable Medical Equipment Medicare Administrative Contractors (DME MAC) Noridian and
CGS recently announced a revision to the LSO/TLSO Policy Article with an effective date of January
1, 2019. The revision provides guidance on the proper coding of prefabricated items which don’t
require substantial modification or minimal self-adjustment.

The revision indicates that when a HCPCS code descriptor does not define a brace as either offthe-shelf (OTS) or custom fitted, it only states prefabricated, the code should be used whether the
device requires custom fitting or is delivered OTS. Here is the full passage from the Policy Article:
“In most cases for prefabricated orthoses, the correct coding of the orthosis is dictated by
actions that take place at the time of fitting to the beneficiary, either custom-fit (requiring
expertise) or off-the-shelf (OTS) (requiring minimal beneficiary self-adjustment). However,
for certain types of orthoses, the HCPCS code narrative that best describes the product does
not make a distinction between prefabricated orthoses that are provided as custom-fit or
OTS. These code narratives are correct and must be used for Medicare billing, without
regard to how the product is provided to the beneficiary at the final delivery.”

Previous interpretations by CMS indicated that if the LSO/TLSO HCPCS code only stated
prefabricated, it was to be considered custom fitted by default. This interpretation was later
reversed and is now clearly stated in the Policy Article.

Questions? Contact Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at
dbernard@AOPAnet.org.