Joint DME MAC and PDAC Article
Posted March 11, 2021
Multiple recent inquires to the Pricing, Data Analysis and Coding (PDAC) Contractor and the Durable Medical Equipment MedicareAdministrative Contractors (DME MAC) have demonstrated the need for education regarding the coding and billing of custom fitted orthotics that do not have a corresponding off-the-shelf equivalent. Orthoses are listed on the PDAC website in the HCPCS to Product and Service Code Crosswalk in the following categories of OR01, OR02 and OR03, and are also identified by specific code descriptions (except certain Cervical and Halo Codes in the table below):
- OR01 - ORTHOSES: CUSTOM FABRICATED
- CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT
- OR02 - ORTHOSES: PREFABRICATED (CUSTOM FITTED)
- PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE
- PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT (emphasis added)
- OR03 - ORTHOSES: OFF-THE-SHELF
- PREFABRICATED, OFF-THE-SHELF
There are certain HCPCS codes categorized as OR02 Custom Fitted Orthotics for which there are no corresponding OR03 Off-the-Shelf codes. If a prefabricated orthosis is categorized as Custom Fitted (OR02), but is delivered as Off-the-Shelf, one of the following miscellaneous codes must be used to bill the DME MAC:
| HCPCS | Description |
|---|---|
| L1499 | Spinal orthosis, not otherwise specified |
| L2999 | Lower extremity orthoses, not otherwise specified |
| L3999 | Upper limb orthosis, not otherwise specified |
Example: A supplier provides a prefabricated device that is listed on the PDAC Product Classification List (PCL) as L3960 (SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT). Two coding options are available for billing this product, based on the actions of the supplier at the time of delivery:
L3960 - Billed if fitting requires alteration beyond minimal self-adjustment (i.e., custom fitting - see below); or,
L3999 - Billed if only minimal self-adjustment adjustment, that can be accomplished by the beneficiary, caregiver or supplier, is necessary.
In this example, when the device requires minimal self-adjustment, the supplier should bill the DME MAC L3999 (Upper limb orthosis, not otherwise specified) because there is not a corresponding prefabricated off-the shelf HCPCS code for L3960.
Custom fitting requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary at the time of delivery. These items cannot be mailed or shipped to the beneficiary [emphasis added] without prior custom fitting of the item. There must be documentation in the orthotist's records to describe how the device was individually fit at the time of delivery to the beneficiary.
Below is a table of HCPCS codes that are classified on the HCPCS to Product and Service Code Crosswalk as OR02: Prefabricated (Custom Fitted) where there is no corresponding Prefabricated Off -the-Shelf HCPCS code.
Prefabricated Custom Fitted Orthotics Without an Off-The-Shelf Equivalent
| HCPCS | Description |
|---|---|
| L0113 | Cranial cervical orthosis, torticollis type, with or without joint, with or without soft interface material, prefabricated, includes fitting and adjustment |
| L0140 | Cervical, semi-rigid, adjustable (plastic collar) |
| L0150 | Cervical, semi-rigid, adjustable molded chin cup (plastic collar with mandibular/occipital piece) |
| L0180 | Cervical, multiple post collar, occipital/mandibular supports, adjustable |
| L0190 | Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars (Somi, Guilford, Taylor types) |
| L0200 | Cervical, multiple post collar, occipital/mandibular supports, adjustable cervical bars, and thoracic extension |
| L0458 | TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment |
| L0460 | TLSO, triplanar control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L0462 | TLSO, triplanar control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in the sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment |
| L0464 | TLSO, triplanar control, modular segmented spinal system, four rigid plastic shells, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to the sternal notch, soft liner, restricts gross trunk motion in sagittal, coronal, and transverse planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment |
| L0470 | TLSO, triplanar control, rigid posterior frame and flexible soft anterior apron with straps, closures and padding, extends from sacrococcygeal junction to scapula, lateral strength provided by pelvic, thoracic, and lateral frame pieces, rotational strength provided by subclavicular extensions, restricts gross trunk motion in sagittal, coronal, and transverse planes, provides intracavitary pressure to reduce load on the intervertebral disks, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment |
| L0472 | TLSO, triplanar control, hyperextension, rigid anterior and lateral frame extends from symphysis pubis to sternal notch with two anterior components (one pubic and one sternal), posterior and lateral pads with straps and closures, limits spinal flexion, restricts gross trunk motion in sagittal, coronal, and transverse planes, includes fitting and shaping the frame, prefabricated, includes fitting and adjustment |
| L0488 | TLSO, triplanar control, one piece rigid plastic shell with interface liner, multiple straps and closures, posterior extends from sacrococcygeal junction and terminates just inferior to scapular spine, anterior extends from symphysis pubis to sternal notch, anterior or posterior opening, restricts gross trunk motion in sagittal, coronal, and transverse planes, prefabricated, includes fitting and adjustment |
| L0490 | TLSO, sagittal-coronal control, one piece rigid plastic shell, with overlapping reinforced anterior, with multiple straps and closures, posterior extends from sacrococcygeal junction and terminates at or before the T-9 vertebra, anterior extends from symphysis pubis to xiphoid, anterior opening, restricts gross trunk motion in sagittal and coronal planes, prefabricated, includes fitting and adjustment |
| L0491 | TLSO, sagittal-coronal control, modular segmented spinal system, two rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment |
| L0492 | TLSO, sagittal-coronal control, modular segmented spinal system, three rigid plastic shells, posterior extends from the sacrococcygeal junction and terminates just inferior to the scapular spine, anterior extends from the symphysis pubis to the xiphoid, soft liner, restricts gross trunk motion in the sagittal and coronal planes, lateral strength is provided by overlapping plastic and stabilizing closures, includes straps and closures, prefabricated, includes fitting and adjustment |
| L0635 | Lumbar-sacral orthosis, sagittal-coronal control, lumbar flexion, rigid posterior frame/panel(s), lateral articulating design to flex the lumbar spine, posterior extends from sacrococcygeal junction to T-9 vertebra, lateral strength provided by rigid lateral frame/panel(s), produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, anterior panel, pendulous abdomen design, prefabricated, includes fitting and adjustment |
| L0810 | Halo procedure, cervical halo incorporated into jacket vest |
| L0820 | Halo procedure, cervical halo incorporated into plaster body jacket |
| L0830 | Halo procedure, cervical halo incorporated into Milwaukee type orthosis |
| L1001 | Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustment |
| L1005 | Tension based scoliosis orthosis and accessory pads, includes fitting and adjustment |
| L1600 | Hip orthosis, abduction control of hip joints, flexible, Frejka type with cover, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1610 | Hip orthosis, abduction control of hip joints, flexible, (Frejka cover only), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1620 | Hip orthosis, abduction control of hip joints, flexible, (Pavlik harness), prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise |
| L1650 | Hip orthosis, abduction control of hip joints, static, adjustable, (Ilfled type), prefabricated, includes fitting and adjustment |
| L1652 | Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, includes fitting and adjustment, any type |
| L1660 | Hip orthosis, abduction control of hip joints, static, plastic, prefabricated, includes fitting and adjustment |
| L1686 | Hip orthosis, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment |
| L1690 | Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment |
| L1820 | Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, includes fitting and adjustment |
| L1831 | Knee orthosis, locking knee joint(s), positional orthosis, prefabricated, includes fitting and adjustment |
| L1910 | Ankle foot orthosis, posterior, single bar, clasp attachment to shoe counter, prefabricated, includes fitting and adjustment |
| L1930 | Ankle foot orthosis, plastic or other material, prefabricated, includes fitting and adjustment |
| L1932 | AFO, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, includes fitting and adjustment |
| L1951 | Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment |
| L1971 | Ankle foot orthosis, plastic or other material with ankle joint, prefabricated, includes fitting and adjustment |
| L2035 | Knee ankle foot orthosis, full plastic, static (pediatric size), without free motion ankle, prefabricated, includes fitting and adjustment |
| L2112 | Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, soft, prefabricated, includes fitting and adjustment |
| L2114 | Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, semi-rigid, prefabricated, includes fitting and adjustment |
| L2116 | Ankle foot orthosis, fracture orthosis, tibial fracture orthosis, rigid, prefabricated, includes fitting and adjustment |
| L2132 | KAFO, fracture orthosis, femoral fracture cast orthosis, soft, prefabricated, includes fitting and adjustment |
| L2134 | KAFO, fracture orthosis, femoral fracture cast orthosis, semi-rigid, prefabricated, includes fitting and adjustment |
| L2136 | KAFO, fracture orthosis, femoral fracture cast orthosis, rigid, prefabricated, includes fitting and adjustment |
| L3931 | Wrist hand finger orthosis, includes one or more nontorsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment |
| L3960 | Shoulder elbow wrist hand orthosis, abduction positioning, airplane design, prefabricated, includes fitting and adjustment |
| L3962 | Shoulder elbow wrist hand orthosis, abduction positioning, Erb's palsy design, prefabricated, includes fitting and adjustment |
| L3980 | Upper extremity fracture orthosis, humeral, prefabricated, includes fitting and adjustment |
| L3981 | Upper extremity fracture orthosis, humeral, prefabricated, includes shoulder cap design, with or without joints, forearm section, may include soft interface, straps, includes fitting and adjustments |
| L3982 | Upper extremity fracture orthosis, radius/ulnar, prefabricated, includes fitting and adjustment |
| L3984 | Upper extremity fracture orthosis, wrist, prefabricated, includes fitting and adjustment |
To identify Prefabricated Custom Fitted codes which have a corresponding Prefabricated Off -the-Shelf HCPCS code, suppliers should reference the joint DME MAC article “Definitions Used for Off-the-Shelf versus Custom Fitted Prefabricated Orthotics (Braces) - Correct Coding - Revised.”
If you have questions, please contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday. You may also visit the PDAC website to chat with a representative or select the Contact Us button at the top of the page for email inquiry, FAX or postal mail information.
Publication History
| Date of Change | Description |
|---|---|
| 03/11/21 | Originally Published |
Last Updated Mon, 15 Mar 2021 17:15:00 +0000