How do you know which HCPCS code to bill for an AFO Custom Fit or OTS - Part II
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The first segment of this two-part article provided some basic information on dual coded products. This second segment will provide some real-life clinical examples of how to decide which code is appropriate:
Let’s look at two scenarios using the same for drop foot brace provided by KevinRoot.
#1: The brace is assembled by KevinRoot according to your measurements. You obtain the device and fit the patient You trim the straps and fit the patient. Which of the paired set codes below is appropriate? L1931 or L1932 or L1951 or L1952
The correct code choice in this first scenario is L1932 or L1952 depending on the brace style you ordered. This scenario would fit into the minimal self-adjustment rules and because no professional custom fitting was performed at the time of delivery, the OTS designation is appropriate.
#2 The brace is shipped to you from KevinRoot and you assembled some of the pieces based on measurements, others were already pre-assembled. At the time of delivery, you drilled a hole or placed the uprights into position screwing them into the foot place. You also heat molded components to properly fit the patient.
Depending on the style of brace one would either be billing for L1931 or L1951.
Some teaching points from the above:
In example #1: Though you took measurements that only a person with expertise could perform and sent them to KevinRoot, that did not take place at the time of delivery. Hence those activities, though conducted by someone with expertise, will not qualify the device as custom fit.
In example #2: The brace was pre-assembled as in #1. However, at the time of delivery, you either drilled holes, or heated the foot plate or upright to properly fit the patient, this would considered custom fit.
The key in correctly coding these dual coded products is totally dependent on what you the supplier does at the time of delivery. This must be well documented in addition to stipulating that you as a physician/orthotist/pedorthist, have the expertise to do so .
From a reimbursement perspective, Medicare’s current regulations preclude reimbursement differentials between OTS and custom fit codes within a code set. Hence, you are paid the same for OTS vs custom fitting.
That may not seem fair, for those submitting custom fit device claims. However, if it were legal, Medicare would likely reduce the reimbursement for OTS and keep the custom fit device at the same price. This may happen if in the future, Competitive Bidding ever includes OTS AFO.
For more information on dual coding codes for AFO provided by KevinRoot please feel free to reach out to our custom support team for advice on your specific coding issues.
