There are significant functional differences between the Xtern (PDAC L1951) braces with them having various features. My advice would be to discuss these differences as they apply to your patient. Since the devices are custom fitted (PDAC O2 category), there are no additional HCPCS codes which are allowed to be billed. There are also some Xtern braces which are validated as L1932 which pay higher than the L1951.Any additional fees you incur for additional add on’s you order for either coded brace, do not have a separate HCPCS code which can be billed to either Medicare (FFS) or Medicare Advantage plans.However, since all Xtern braces attach to the shoe, if a foot orthotic device is required on the brace side, it is reimbursable under the Orthopedic Footwear policy. The rationale is that under this policy, foot orthotics are covered when they are placed into a shoe which is attached to a brace. The appropriate L-Code for the orthtoic would be first amended with the KX modifier and second with a site modifier (LT or RT).Also the contralateral limb which does not have a brace, if it requires a foot orthotic, will not be covered by traditional Fee for Service Medicare (and likely not by Medicare Part C Plan).That is a cash service and the L-code for that side would be amended with GY (statutorily not covered) as the first modifier and second with a site modifier (LT or RT).
Note that the payment limitations cited above (surcharge for additional features you add to the Xtern) are limited to only Medicare recipients. One would need to check the patient’s third party coverage if they are not Medicare beneficiaries.
The new XTERN Summit is a carbon brace, and the provider pays the product vendor hundreds of dollars more for it than for the XTERN classic, which is made of plastic. Both are PDAC-certified L1951.
Because the XTERN summit costs the provider more, can the provider charge the patient cash for the difference in cost if the patient wants the carbon brace over the plastic brace?
There are significant functional differences between the Xtern (PDAC L1951) braces with them having various features. My advice would be to discuss these differences as they apply to your patient. Since the devices are custom fitted (PDAC O2 category), there are no additional HCPCS codes which are allowed to be billed. There are also some Xtern braces which are validated as L1932 which pay higher than the L1951.Any additional fees you incur for additional add on’s you order for either coded brace, do not have a separate HCPCS code which can be billed to either Medicare (FFS) or Medicare Advantage plans. However, since all Xtern braces attach to the shoe, if a foot orthotic device is required on the brace side, it is reimbursable under the Orthopedic Footwear policy. The rationale is that under this policy, foot orthotics are covered when they are placed into a shoe which is attached to a brace. The appropriate L-Code for the orthtoic would be first amended with the KX modifier and second with a site modifier (LT or RT). Also the contralateral limb which does not have a brace, if it requires a foot orthotic, will not be covered by traditional Fee for Service Medicare (and likely not by Medicare Part C Plan).That is a cash service and the L-code for that side would be amended with GY (statutorily not covered) as the first modifier and second with a site modifier (LT or RT).
Note that the payment limitations cited above (surcharge for additional features you add to the Xtern) are limited to only Medicare recipients. One would need to check the patient’s third party coverage if they are not Medicare beneficiaries.
The answer is NO, as stated they are both PDAC L1951.
The new XTERN Summit is a carbon brace, and the provider pays the product vendor hundreds of dollars more for it than for the XTERN classic, which is made of plastic. Both are PDAC-certified L1951.
Because the XTERN summit costs the provider more, can the provider charge the patient cash for the difference in cost if the patient wants the carbon brace over the plastic brace?