Retired - Incorrect Use of HCPCS Codes for Custom Fit Orthotics

Joint DME MAC and PDAC Article

The DME MACs have recently been made aware of the inappropriate use of HCPCS codes which are considered custom fit orthotics. There are specific HCPCS codes that are considered custom fit orthotics and require more than minimal self-adjustment, as published on the PDAC website on the HCPCS to Product and Service Code Crosswalk.

Custom fitting requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary at the time of delivery. These items cannot be mailed or shipped to the beneficiary [emphasis added] without prior custom fitting of the item. There must be documentation in the orthotist's records to describe how the device was individually fit at the time of delivery to the beneficiary.

If the product is categorized as custom fit and is delivered as off-the-shelf, one of the following miscellaneous codes must be used to bill the DME MAC:

• L1499 (Spinal orthosis, not otherwise specified)
• L2999 (Lower extremity orthoses, not otherwise specified); or
• L3999 (Upper limb orthosis, not otherwise specified)

Suppliers should also reference the joint DME MAC article Correct Coding – Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) – Revised published on the four DME MAC's websites.

If you have questions, please contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday. You may also visit the PDAC website to chat with a representative or select the Contact Us button at the top of the page for email inquiry, FAX or postal mail information.