Last Modified: 7/6/2020
Location: FL, PR, USVI
Business: Part B
Following this guidance will help your patients and the Medicare program by verifying there is medical record documentation to support the provision of lower limb orthoses (LLO).
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 LLO, review local coverage determinations (LCDs) and policy articles for Ankle-Foot/Knee-Ankle-Foot Orthoses (L33686 and A52457) and Knee Orthoses (L33318 and A52465). You can locate these LCDs and policy articles from the Centers for Medicare & Medicaid Services Medicare Coverage Database
The durable medical equipment prosthetics, orthotics and supplies (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 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)
• Beneficiary’s name
• Date of the order
• A description of all items, options, accessories or additional features that are separately billed or require an upgraded code
• Descriptions can be general (e.g., wheelchair or hospital bed), a Healthcare Common Procedure Coding System (HCPCS) code, a HCPCS code narrative, or a brand name/model number
• Prescribing physician/practitioner’s signature (and date of applicable)
LCDs and policy articles for LLO can be located on the DME MAC contractor websites:
DME MAC Jurisdiction A
(CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, District of Columbia)
DME MAC Jurisdiction C
(AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, SC, TN, TX, VA, WV, Puerto Rico, U.S. Virgin Islands)
DME MAC Jurisdiction D
(AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY, American Samoa, Guam, Northern Mariana Islands)
First Coast Service Options (First Coast) strives to ensure that the information available on our provider website is accurate, detailed, and current. Therefore, this is a dynamic site and its content changes daily. It is best to access the site to ensure you have the most current information rather than printing articles or forms that may become obsolete without notice.