Feeling the Effects of OTS


There is a new and alarming trend in Medicare audits. Recent reports from the Jurisdiction B and Jurisdiction D DME MACs indicate that they are actively auditing claims involving orthoses that can be delivered as either custom fitted or OTS and the results are not encouraging.

Jurisdiction D recently reported a 100% error rate on its prepayment review of claims for knee orthoses described by L1832, L1833, and L1843 and Jurisdiction B reported a prepayment error rate of 96% on claims for a broad range spinal orthoses. In both of these reports, lack of a detailed description of the modifications necessary at the time of fitting the orthosis to the beneficiary was listed as one of the reasons for claim denials. While the DME MAC LCDs and Policy Articles were revised to incorporate language requiring documentation to support the need of a custom fitted orthosis over an OTS orthosis in January of 2014, these recent reports signal the first instances where the DME MACs are actually denying claims based on this criteria.

AOPA’s take on these reports is one of trepidation. O&P providers must be aware of the need to document the specific modifications to the orthosis that are required when providing a custom fitted orthosis. In addition, the referring physician must also document the medical need for a custom fitted orthosis rather than an OTS orthosis. These documentation requirements create yet another hurdle in the attempt to provide medically necessary services to Medicare beneficiaries, one that is now being used as yet another reason for the DME MACs to deny claims.

AOPA continues its dialogue with the DME MACs and CMS surrounding all of the issues the introduction of the split code set in 2014 created. These audits represent yet another argument in AOPA’s efforts to ensure fair treatment of O&P providers.

AOPA’s Take……..Where you go when you need to know!