Joint DME/PDAC Coding Bulletin Provides Clarification on Proper Billing of Prefabricated Orthoses


On March 11, 2021, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Pricing, Data Analysis, and Coding Contractor (PDAC) published a joint correct coding bulletin regarding code descriptors that include the term “prefabricated, includes fitting and adjustment”.

In 2014, the Centers for Medicare and Medicaid Services (CMS) introduced a series of procedure code pairs that included both an off-the-shelf (OTS) version and a version that requires custom fitting by an individual with appropriate expertise and or training.  A total of 51 orthotic HCPCS codes did not have their descriptors changed and continued to simply state, “prefabricated, includes fitting and adjustment.”  The March 11, 2021 coding bulletin indicates that HCPCS codes that include the term, “prefabricated, includes fitting and adjustment” are appropriately classified as custom fitted orthoses and therefore may only be used to describe orthoses that require customization and/or modification by a certified orthotist or other properly trained individual.  Orthoses described by these codes that are delivered as OTS, without customization and/or modification must be billed using the appropriate not otherwise specified code (L1499, L2999, L3999).  The bulletin also emphasizes that, like all custom fitted codes, orthoses that are billed using one of the 51 HCPCS codes that include the term, “prefabricated includes fitting and adjustment” may not be shipped or mailed to Medicare beneficiaries without clear documentation of the customization and/or modification that was performed to ensure a proper fit.

AOPA continues to support the provision of orthoses by individuals with the appropriate clinical expertise, training, and relevant certification/licensure to ensure patients receive high quality, clinically appropriate care.  AOPA is reviewing the correct coding bulletin and will provide constructive feedback to the DME MACs/PDAC.

View the correct coding bulletin.

Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.