Coding Issues

2021 HCPCS Code Updates

The Centers for Medicare and Medicaid Services (CMS) has released two new Healthcare Common Procedure Coding System (HCPCS) codes effective April 1, 2021.

  • K1014 -Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control
  • K1015-Foot, adductus positioning device, adjustable

Correct Coding of Custom Fitted Orthotic HCPCS Codes Without a Corresponding OTS Code

The DME MACs and the PDAC published a joint correct coding bulletin regarding code descriptors that include the term “prefabricated, includes fitting and adjustment”. A total of 51 orthotic HCPCS codes simply state, “prefabricated, includes fitting and adjustment”, or do not have a corresponding off-the-shelf code, and are to be classified as custom fitted orthoses, and therefore may only be used to describe orthoses that require customization and/or modification by a certified orthotist or other properly trained individual.  Orthoses described by these 51 codes that are delivered as OTS, without customization and/or modification must be billed using the appropriate not otherwise specified code (L1499, L2999, L3999).  View the correct coding bulletin.

Correct Coding for Prefabricated Bilateral Lumbo-sacral Hip Orthosis

The DME MACs and PDAC have provided correct coding guidelines for items described by L1690 (Combination, bilateral, lumbo-sacral, hip, femur orthosis providing adduction and internal rotation control, prefabricated, includes fitting and adjustment) must have, at a minimum, the following characteristics: contains left and right hip joints specialized for combined planar motion, each hip joint uses rigid connectors for attachment to a rigid lumbo-sacral component to maintain therapeutic alignment, rigid lumbo-sacral component wraps around the posterior pelvis, includes anterior closures, lumbo-sacral component extends from the distal sacrum to L2/L3, hip joints align the femurs in abducted posture (set by supplier), each thigh cuff attaches to the rigid distal upright of each hip joint, includes closures, and may be worn when seated and during ambulation.

Coding Verification for Hip Abduction Orthosis

The DME MACs and the PDAC released a correct coding reminder for the hip abduction orthosis, L1686 (HO, abduction control of hip joint, postoperative hip abduction type, prefabricated, includes fitting and adjustment).  L1686 contains a semi-rigid or rigid waistband connected to a single rigid upright, hip joint and rigid thigh cuff.  The hip joint is adjustable for extension/flexion as well as abduction; the hip joint aligns and maintains the femur in an abducted position. The L1686 is also considered to be a complete product/device. It is also considered to be custom fitted and requires more than minimal self-adjustment at the time of delivery and requires the expertise of a certified orthotist or an individual who has specialized training in the provision of an orthosis to fit the item to the beneficiary.

Coding Verification for Lower Limb Prostheses

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and Pricing, Data Analysis, and Coding Contractor (PDAC) released a joint announcement for a new coding verification requirement for the six lower limb prostheses. Effective for claims with dates of service on or after January 1, 2021, the only products which may be billed using codes L5856, L5857, L5858, L5973, L5980, and L5987 are those for which a written Coding Verification Review has been made by the PDAC and is listed on the PDAC Product Classification List.  The joint publication announcing the coding verification requirement may be viewed here.

Coding Reminder for Scoliosis Braces

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Pricing, Data Analysis and Coding (PDAC) contractor just released a correct coding reminder for five base codes used to describe scoliosis braces: L1000, L1005, L1200, L1300 and L1310.  A copy of the full correct coding reminder may be found here.

Items Requiring Coding Review by the PDAC

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 and the PDAC’s Product Classification List.


For more CMS coding updates and reminders please review the PDAC Advisory Articles.