Custom vs. OTC
A recent requirement for all custom-foot orthoses prescriptions is verification that a prefabricated device “could not be fit” to the specific patient.
This used to be optional for custom AFO prescriptions but it is now is an absolute necessity for documentation in the medical record.
The record must specifically state that the patient “could not be fit with a prefabricated AFO”… which the meaning is vague and confusing.
We suggest that severe deformity will preclude the fitting of a prefabricated device and the specifics of the deformity should be spelled out. Alternatively, the practitioner can try to fit a prefabricated Richie Brace® in the office and document that proper fit could not be achieved.
In addition, one more criteria for prescribing a custom AFO device must be documented in the medical record. The criteria should be selected from the following list, i.e. pick all that apply:
- Condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or
- There is a need to control the knee, ankle, or foot in more than one plane; or
- Patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or
- Patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.
Note: In almost all cases, custom Richie Brace® products are utilized to control the ankle and foot in more than one plane. In many cases, the condition is expected to be treated for a duration exceeding 6 months.
We suggest at least 2 criteria be utilized and appear in narrative form in the patient medical record.
Effective for claims with dates of service (DOS) on or after 3/1/2019, suppliers must bill each item on two separate claim lines using the RT and LT Modifiers and 1 USO on each claim line. Do not use the combination RTLT modifier on the same claim line and bill with 2 unites of service (UOS). Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or with the RTLT on a single line, will be rejected as incorrect coding.