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.
The download section of this web page contains a list that initially identifies the 2012 Healthcare Common Procedure Coding System (HCPCS) codes that are 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. Please note that the inclusion of a HCPCS code on the OTS orthotics list does not imply any health insurance coverage. 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. OTS orthotics are not a product category for the Round 2 and National Mail-Order Competition. 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.
CMS will accept electronic comments on the list of OTS HCPCS codes through Thursday, March 8, 2012. Comments may be submitted via email to OTSComments@cms.hhs.gov.
- Page last Modified: 03/14/2012 10:04 AM
- Help with File Formats and Plug-Ins