Off-The-Shelf (OTS) Orthotic HCPCS Codes
Section 1847(a)(2) of the Social Security Act (the Act) defines OTS orthotics as those orthotics described in section 1861(s)(9) of the Act for which payment would otherwise be made under section 1834(h) of the Act, which require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit to the individual. Orthotics that are currently paid under section 1834(h) of the Act and are described in section 1861(s)(9) of the Act are leg, arm, back and neck braces. The Medicare Benefit Policy Manual (Publication 100-02), Chapter 15, Section 130 provides the longstanding Medicare definition of “braces.” Braces are defined in this section as “rigid or semi-rigid devices which are used for the purpose of supporting a weak or deformed body member or restricting or eliminating motion in a diseased or injured part of the body.”
CMS regulations at 42 CFR 414.402 also define the term “minimal self-adjustment” to mean an adjustment that the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training.
On February 9, 2012, CMS issued guidance that initially identified specific HCPCS codes that were considered OTS orthotics. CMS solicited public comments on the preliminary list of OTS HCPCS codes and received approximately 185 comments. All public comments were reviewed and grouped by topic. The download section of this web page contains a summary of the comments and our responses as well as a list that identifies the 2014 Healthcare Common Procedure Coding System (HCPCS) codes considered OTS orthotics. Items classified under these codes require minimal self-adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling, or customizing to fit the beneficiary. Subsequent coding updates to the OTS list will be included in program instructions.
Section 1847(a)(2) of the Act includes OTS orthotics as one of the categories of items subject to competitive bidding. CMS has not determined the schedule for bidding OTS orthotics, but will identify the specific OTS orthotic codes included in a competitive bidding program through program instructions or by other means, such as a CMS or contractor website posting.
- Page last Modified: 08/12/2013 9:49 AM
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