Podiatry Coding & Billing Alert

Hint: You must understand the difference between minimal and substantial self-adjustment.

It’s no secret that coding for ankle-foot orthoses (AFOs) can be extremely challenging. You must look for a ton of detail in the documentation and know which code corresponds with the appropriate details. You must also be able to differentiate between custom-fit and off-the-shelf orthotics (OTS) because the requirements and codes are different for each kind of device.

Coding for orthotics is a very confusing topic, and the requirements change within each MAC, explains Arnold Beresh, DPM, CPC, CSFAC, in West Bloomfield, Michigan.

Take a look at the handy chart below, with certain terms explained in more detail after, to help you better understand the differences between custom-fit and OTS orthotics.

Editor’s note: We used the LCD L33686 and the policy article A52457, which the MACs CGS and Noridian follow, as the basis of our research. Other MACs may include different details when describing orthotics, so you always want to check with your specific MAC if you are uncertain. 

*Kits defined: Noridian defines a kit as, “A collection of components, materials and parts that require further assembly before delivery of the final product. The elements of a kit may be packaged and complete from a single source or may be an assemblage of separate components from multiple sources by the supplier.” Important: Assembling the device or installing add-on components or using some basic materials to prep the device does not change its classification from OTS to custom-fit.

*Minimal self-adjustment defined: Medicare defines minimal self-adjustment as “an adjustment the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist … or an individual who has specialized training.” OTS orthotics require minimal self-adjustment.

*Substantial adjustment defined: Medicare defines substantial modification as any changes the provider makes to the orthotic to individually fit the patient. A certified orthotist or individual who has had the equivalent of specialized training in providing orthotics must provide the substantial modification. Custom-fit orthotics require substantial modification.