custom vs. prefab responses
Shane Cleveland
Description
Collection
Title:
custom vs. prefab responses
Creator:
Shane Cleveland
Date:
1/28/2010
Text:
Thank you for all of the responses. Opinions seem to favor the product I described as custom fabricated, since it is created using measurements for a specific individual, regardless of the need to later custom fit it to the patient. It seems those who considered it prefabricated felt a positive casting was required or that it needed to be fabricated on site by practitioner.
Original question:
If a product is fabricated according to measurements, tracings, etc. taken by a medical professional, I assume that is considered custom fabricated. However, if the product also requires further molding by the medical professional to the individual patient once it is received, does the custom fitting no longer make it a custom fabricated product?
Would you choose a custom-fabricated L-Code or a prefabricated L-Code for billing?
Responses:
1. UE is a grey area, because the L codes are old. I use this rule - If fabricated from a cast, it is custom. If fabricated from measurements and then adjusted for proper fit (or fitted), then it is prefabricated.
2. The orthosis that you described would be a custom made device whether modifications were made or not. It should be billed using the Custom L-Code(s). It would be custom fitted if the device was generically produce but required expert fitting to insure proper function and that it meets the requirement of the prescription.
IL statute would require that the delivery of the custom orthosis be conducted or supervised by an individual licensed by the state. Your company's orthoses legally would require a Licensed Physician, Licensed Therapist (OT or PT) or a Licensed Orthotist (or LPO) here.
A device that the patient has chosen for his/her self that comes out of a box or off of the display shelf does not require a licensed caregiver.
3. As I understand the CMS quidelines, custom fitted is when a device that is made to a standard model (pre-made) is then modified to fit a specific patient. As far as I can find there are no guidelines as to amount of fitting required (or lack of) to constitute custom fitted. Simply that a pre-made device is used and any steps required to fit to individual are taken.
Custom made is defined as a device that is manufactured from an image of a specific patient (tracing, scan, cast, mmt, x-ray, etc). Any additional fitting does not make it any less custom, but is rather a continuation of the fabrication process.
4. Is it made over a specific mold specifically created for the patient based upon the Mx?
Is the item made over a pre-existing model of a similarly shaped and conforming person?
Ask AOPA, and also, you can ask Medicare for an evaluation/opinion of the process. I know other items have a medicare approved L-code.
5. In my opinion that would be prefab since custom is defined usually by being made from a positive model from a cast
6. We use your stuff all the time with the heat moldable inserts and we bill them as custom fabricated because they are custom to measurement. The moldable panel is an aside and we don't consider this to change the base code. Hope this helps
7. Custom on those measured and fabricated specifically for those measurements. A pattern would need to be made and followed. Pre-fabricated code on the one that is mass produced and needs minor changes/modifications to correctly fit the patient.
8. The keyword is now modified. Let me give you an example. Practitioners who order custom body jackets sometimes do so with a set of measurements. These measurements are sent to the fabricator, who selects a template model that is relatively close to the measurements provided. If the orthosis was fabricated from this model, prior to receiving any patient measurements, it would be prefabricated, that is with no specific patient in mind. However, once any modifications are made to this model, specific to an individual patient, then it is custom (specifically fabricated for THAT patient). Any modifications to the custom orthosis is simply termed adjustments, not further customization. An example of customized is taking a prefabricated orthosis and modifying it in some manner to fit the patients anatomy. Thus customized and custom are two different things.
Look up the difference between A5510, A5512 and A5513. Prefab vs Customized vs Custom.
9. The guiding wisdom is if you modify a ready made produce, it is billed as prefabricated as the HCPCS code includes fitting and adjustment. Should the splint be made from scratch from sheet material or a blank, it is custom fabricated. The increase in reimbursement is due to the additional time needed to make the device.
10. I would consider it a prefabbed device no matter how much modification is needed. One may take 5 mins. to fit, another might take 20 mins. If it needs more than that you were better off fabbing a custom device from the start which being a professional, you should have known that the prefabbed device would warrant such extensive mods.
11. I believe that if the item is made from measurements for one specific patient, it is considered custom fabricated, regardless whether or not it needs additional adjustments for proper fitting. I would bill as custom fabricated, because it was.
12. Custom fabricated doesn't mean it fits perfectly and may not adjustments
Original question:
If a product is fabricated according to measurements, tracings, etc. taken by a medical professional, I assume that is considered custom fabricated. However, if the product also requires further molding by the medical professional to the individual patient once it is received, does the custom fitting no longer make it a custom fabricated product?
Would you choose a custom-fabricated L-Code or a prefabricated L-Code for billing?
Responses:
1. UE is a grey area, because the L codes are old. I use this rule - If fabricated from a cast, it is custom. If fabricated from measurements and then adjusted for proper fit (or fitted), then it is prefabricated.
2. The orthosis that you described would be a custom made device whether modifications were made or not. It should be billed using the Custom L-Code(s). It would be custom fitted if the device was generically produce but required expert fitting to insure proper function and that it meets the requirement of the prescription.
IL statute would require that the delivery of the custom orthosis be conducted or supervised by an individual licensed by the state. Your company's orthoses legally would require a Licensed Physician, Licensed Therapist (OT or PT) or a Licensed Orthotist (or LPO) here.
A device that the patient has chosen for his/her self that comes out of a box or off of the display shelf does not require a licensed caregiver.
3. As I understand the CMS quidelines, custom fitted is when a device that is made to a standard model (pre-made) is then modified to fit a specific patient. As far as I can find there are no guidelines as to amount of fitting required (or lack of) to constitute custom fitted. Simply that a pre-made device is used and any steps required to fit to individual are taken.
Custom made is defined as a device that is manufactured from an image of a specific patient (tracing, scan, cast, mmt, x-ray, etc). Any additional fitting does not make it any less custom, but is rather a continuation of the fabrication process.
4. Is it made over a specific mold specifically created for the patient based upon the Mx?
Is the item made over a pre-existing model of a similarly shaped and conforming person?
Ask AOPA, and also, you can ask Medicare for an evaluation/opinion of the process. I know other items have a medicare approved L-code.
5. In my opinion that would be prefab since custom is defined usually by being made from a positive model from a cast
6. We use your stuff all the time with the heat moldable inserts and we bill them as custom fabricated because they are custom to measurement. The moldable panel is an aside and we don't consider this to change the base code. Hope this helps
7. Custom on those measured and fabricated specifically for those measurements. A pattern would need to be made and followed. Pre-fabricated code on the one that is mass produced and needs minor changes/modifications to correctly fit the patient.
8. The keyword is now modified. Let me give you an example. Practitioners who order custom body jackets sometimes do so with a set of measurements. These measurements are sent to the fabricator, who selects a template model that is relatively close to the measurements provided. If the orthosis was fabricated from this model, prior to receiving any patient measurements, it would be prefabricated, that is with no specific patient in mind. However, once any modifications are made to this model, specific to an individual patient, then it is custom (specifically fabricated for THAT patient). Any modifications to the custom orthosis is simply termed adjustments, not further customization. An example of customized is taking a prefabricated orthosis and modifying it in some manner to fit the patients anatomy. Thus customized and custom are two different things.
Look up the difference between A5510, A5512 and A5513. Prefab vs Customized vs Custom.
9. The guiding wisdom is if you modify a ready made produce, it is billed as prefabricated as the HCPCS code includes fitting and adjustment. Should the splint be made from scratch from sheet material or a blank, it is custom fabricated. The increase in reimbursement is due to the additional time needed to make the device.
10. I would consider it a prefabbed device no matter how much modification is needed. One may take 5 mins. to fit, another might take 20 mins. If it needs more than that you were better off fabbing a custom device from the start which being a professional, you should have known that the prefabbed device would warrant such extensive mods.
11. I believe that if the item is made from measurements for one specific patient, it is considered custom fabricated, regardless whether or not it needs additional adjustments for proper fitting. I would bill as custom fabricated, because it was.
12. Custom fabricated doesn't mean it fits perfectly and may not adjustments
Citation
Shane Cleveland, “custom vs. prefab responses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/231065.
