2013 HCPCS Codes Released (11/5/2012)

The Centers for Medicare and Medicaid Services (CMS) has released the new HCPCS codes for 2013. There were few changes to the codes that describe orthotics and prosthetics for 2013.  Below is a breakdown of the new code(s) and code descriptor changes; there were no code deletions.   

 New Code

Code	Descriptor
L5859	Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control, includes any type motor(s)

Code Descriptor Changes

Four "L" codes had their descriptor changed. The L5972 was changed to delete the references to any one specific product.

The L8000, L8001, and L8002 code descriptors were changed to reflect a revision that was made in the External Breast Prosthesis Policy in June of this year.  The revision in the policy provided updated coding guidelines and stated that the L8000 describes a bra, without an integrated breast prosthesis, which has pockets designed to hold mastectomy form/breast prosthesis adjacent to the chest wall and codes L8001 and L8002 describe mastectomy bras with integrated breast prosthesis. The L8000, L8001 and L8002 also include the following characteristics:

Code	Old Descriptor	New Descriptor
L8000	Breast prosthesis, mastectomy bra	Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type
L8001	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, unilateral, any size, any type
L8002	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral	Breast prosthesis, mastectomy bra, with integrated breast prosthesis form, bilateral, any size, any type
L5972	All lower extremity prostheses, flexible keel foot (Safe, Sten, Bock Dynamic or equal)	All lower extremity prostheses, foot, flexible keel

 

AOPA's Coding and Reimbursement Committee will review the list of changes and provide appropriate comments to CMS.  

Items Requiring Coding Review by the PDAC (10/10/2012)

Manufacturers and patient care facilities are reminded that a number of items require coding review by the Pricing, Data Analysis and Coding (PDAC) contractor; and a PDAC coding review is binding when billing Medicare. Here is a list of items which require a PDAC coding review:

• LSOs and TLSOs: Any prefabricated spinal orthoses  described by codes  L0450, L0454-L0472, L0488-L0492, L0625-L0628, L0630, L0631, L0633, L0635, L0637 and L0639.  Any custom fabricated spinal orthoses fabricated by a central fabrication facility or manufacturer described by codes L0452, L0480-L0486, L0629, L0632, L0634, L0636, L0638 and L0640.  If you fabricated a custom LSO or TLSO in-house and provide it directly to the patient, you don’t have to have the product verified by the PDAC. However, you must be able to provide a list of materials used and a description of your fabrication process if requested.
• Diabetic Shoes and Inserts: All prefabricated diabetic shoe inserts, A5512, must be reviewed and verified by the PDAC. Custom fabricated inserts, A5513, also require PDAC coding verification if fabricated by a central fabrication facility or manufacturer. If you fabricate a custom insert in-house and provide it directly to the patient, you don’t have to have the insert verified by the PDAC. However, you must be able to provide a list of materials used and a description of your fabrication process if requested.
• KOs: A prefabricated double upright knee orthosis described by code L1845.
• AFOs:  A prefabricated multiligamentous support described by code L1906.
• Miscellaneous: A cervical collar described by code L0174 and a functional electric stimulator described by code E0770.

 

Diabetic Inserts & Partial Feet Inserts (09/12/2012)

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have issued guidance on how to bill for diabetic inserts (A5512 and A5513) when the patient also requires a partial foot insert (L5000).

The L5000 includes a rigid longitudinal arch support and includes the addition of materials to fill the void of the missing digits, and the addition of softer materials in areas where the residual limb makes contact with the insert. The L5000 is designed to provide standing balance and toe off support for the patient to improve their gait. Diabetic inserts are designed with multiple layers of materials varying in destiny to provide a protective function for the foot and is part of the patient’s diabetes management efforts.

If the patient has diabetes and does not require the extra rigidity and support provided by the L5000, because they are only missing toes; excluding the big toe (hallux), you may only bill for the A5513 (custom diabetic insert) and not the L5000. In this scenario the customization of the A5513 includes the addition of materials to replace the missing digits.

If the patient has diabetes and requires the extra rigidity and support provided by the L5000, because they are missing the hallux or forefoot you may only bill for the L5000 and you may not also bill for an A5512 or A5513. In this scenario the provision of the L5000 includes the addition of materials to replace the missing digits, and the materials added to create the protective function as part of the patient’s diabetes management.

Coding Guidelines for External Breast Prostheses: L8000, L8001 and L8002 (05/16/2012)

HCPCS code L8000 describes a bra, without an integrated breast prosthesis, which has pockets designed to hold mastectomy form/breast prosthesis adjacent to the chest wall and codes L8001 and L8002 describe mastectomy bras with integrated breast prosthesis. The L8000, L8001 and L8002 also include the following characteristics:

• May be constructed of any material including but not limited to cotton and polyester
• May included any type of closure and the closure may be located anywhere on the bra
• May be of any size
• May be constructed with or without integrated structural support ,e.g., an underwire

Any of the above features may not be billed as an add on or as a deluxe feature.

 

Concentric Joints (05/08/2012)

The Pricing, Data Analysis and Coding contractor (PDAC) and Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have revised the coding guidelines for the use of concentric adjustable torsion joints used with prefabricated and custom fabricated orthoses.

If the concentric adjustable torsion joints are used solely to provide an assistive function for joint motion, you may use the L2999 for lower extremity orthoses and L3999 for upper extremity orthoses. All other uses of concentric adjustable torsion joints must be coded and billed as the following:

• E1800 - Dynamic adjustable elbow extension/flexion device
• E1802 - Dynamic adjustable forearm pronation/supination device
• E1805 - Dynamic adjustable wrist extension/flexion device
• E1810 - Dynamic adjustable knee extension/flexion device
• E1815 - Dynamic adjustable ankle extension/flexion device

As a reminder any claim for an L2999 or L3999 must include either a narrative description of the item or the manufacturer name and model name/number.

 

Cosmetic Hand Restoration Coding (05/06/2012)

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have stated that L6895 (addition to upper extremity prosthesis, glove for terminal device, any material, custom fabricated) should be used to describe and bill for all cosmetic features such as coloring, veins, hair, etc. Providers should no longer use L7499 (upper extremity prosthesis, not otherwise specified) to describe these cosmetic features.

AFO Coding Guidelines (12/21/2011)

The Pricing, Data Analysis and Coding (PDAC) Contractor has issued coding guidelines for three L codes related to Ankle Foot Orthoses (AFO).

• L2340 ( addition to lower extremity, pre-tibial shell, molded to patient model), must provide a rigid overlapping interlocking anterior tibial control between the tibial tuberosity and extend to a point no greater than 3 inches proximal to the medial malleolus. The L2340 must also be fabricated from thermosetting materials, thermoplastics, or composite type materials.
• L1906 (AFO, multiligamentous ankle support, prefabricated, includes fitting and adjustment),must provided control of the ankle joint between the medial and lateral malleoli while allowing for dorsiflexion and plantar flexion and include wrap around straps, a rigid stirrup and foot plate, which provides functional tracking of the ankle with hind-foot and mid-foot stability during ambulation. The PDAC has also stated that no addition codes may be added to the L1906.
• L1960 (AFO, Posterior solid ankle, plastic, custom fabricated), the proximal border should extend to a height no greater than 1.5 inches distal to the apex of the head of the fibula.

Prosthetic Hand & Articulating Digits Coding Guidelines (12/21/2011)

The Pricing, Data Analysis and Coding (PDAC) Contractor has issued guidance on the proper use of the following two prosthetic codes:

• L6715 - Terminal device, multiple articulating digit, includes motor(s), initial issue or replacement.
• L6880- Electric hand, switch or myoelectric controlled, independently articulating digits, any grasp pattern or combination of grasp patterns, includes motor(s).

When initially providing multiple articulating digits (e.g. finger or thumb) the code L6715 must be paired with a partial hand base code (L6000, L6010 or L6020). The L6715 may not be billed with the base code of L6025.

The L6880 is considered to be a complete hand prosthesis, which consists of the terminal device, all articulating digits and motors and all necessary components. The L6715 may not be used as an addition to the L6880; if the L6715 is used with the L6880 your claim will be denied.

 If you are replacing a multiple articulating digit(s) as part of a repair, you may use the L6715 and the RB modifier.