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Printed Date: 9/22/2015
Following this guidance outlined in this article will help your patients and the Medicare program by verifying there is documentation in the medical record to support the provision of lower limb orthoses.
Medicare coverage requires the patient's medical record to show the orthosis is reasonable and necessary for the diagnosis or treatment of illness or injury, or to improve the functioning of a malformed body member.
For coverage criteria related to lower limb orthoses, review Local Coverage Determinations (LCD) and Policy Articles for Ankle-Foot Orthoses/Knee-Ankle-Foot Orthoses (L33686 and A52457) and Knee Orthoses (L33318 and A52465).
The DMEPOS supplier must have a verbal/dispensing/preliminary order prior to providing the orthosis. The supplier cannot submit a claim for reimbursement until a complete detailed written order is received. The detailed written order must contain the elements listed in the chart below. Help your patient by providing this in a timely manner. In addition to the “reasonable and necessary” criteria outlined in the LCD there are additional payment rules related to documentation requirements. For details related to documentation requirements, review the Local Coverage Article (LCA) for Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426).
Date of the order
A description of all items, options, accessories or additional features that are separately billed or require an upgraded code. The description can be a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
Prescribing physician/practitioner's signature (and date, if applicable).
LCDs and policy articles for lower limb orthoses can be located on the DME MAC contractor websites:
Jurisdiction A — Connecticut, District of Columbia, Delaware, Massachusetts, Maryland, Maine, New Hampshire, New Jersey, New York (entire state), Pennsylvania, Rhode Island, Vermont
Jurisdiction B — Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio, Wisconsin
Jurisdiction C — Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, Virgin Islands, Virginia, West Virginia
Jurisdiction D — Alaska, American Samoa, Arizona, California (entire state), Guam, Hawaii, Iowa, Idaho, Kansas, Missouri (entire state), Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Northern Mariana Islands
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Last Updated: 11/22/2019