One of the most common questions our company gets regarding the billing and coding of orthopedic bracing is what type of brace to prescribe and dispense? When it comes to bracing, the two main classifications are off-the-shelf and custom prefabricated. Knowing the difference can be very important in order to remain compliant.
The first type of orthopedic bracing is custom prefabricated. Examples of these codes for lumbar braces are Lo627, Lo631 and Lo637. These braces are required to be trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise. You may ask, who is considered a person with expertise? This becomes a bit complicated based on the insurance you are billing. According to Medicare, a person with expertise is an Orthotist/ Prosthetist, MD, DO, APRN or PA.
What is required to custom fit a brace? Many of the bracing manufacturers provide documentation worksheets showing the steps needed to customize a specific brace whether it be lumbar, knee or wrist. This includes steps on how the patient was measured, how the product was trimmed, and/or how it was molded to specifically fit the patient. This document needs to be filled out in detail to remain compliant when dispensing these custom prefabricated braces.
The second type of orthopedic bracing is the off-theshelf or OTS. OTS braces are the most common braces being dispensed by providers. According to CGS Medicare, these braces require minimal self-adjustment for fitting at the time of delivery. Fitting these OTS braces does not require fitting by a person with expertise. Essentially, these braces should be able to be taken out of the package and adjusted to fit the patient by simply reading the instructions.
The reimbursement between the custom prefabricated and the off-the-shelf does differ. Since there is more of a fitting required, the custom prefabricated braces reimburse higher. Many of the brace manufacturers have had their products dual-coded. This Way, physicians can choose how they would like to fit the patient. Many patients need more of a custom fit, and others just need a standard fit. One code will be the custom prefabricated code and one will be the OTS code. When dispensing orthopedic bracing it is very important to know the difference between the different classifications. At JMS Med Supply, we can provide physicians and billing personnel with the necessary documents in order to bill both classifications of orthopedic bracing.
When it comes to bracing, the two main classifications are off-the-shelf and custom prefabricated. Knowing the difference can be very important in order to remain compliant.
Matt Snyder
PRESIDENT, JMS MED SUPPLY
