Coding Issues


2018 HCPCS Code Changes

The following tables identify changes to Level II Healthcare Common Procedure Coding System (HCPCS) codes for 2018. All HCPCS code changes are effective for claims with dates of service on or after January 1, 2018

New Codes

Code Descriptor
L3761 Elbow orthosis with adjustable position locking joint(s), prefabricated, off-the-shelf
L7700 Gasket or seal, for use with prosthetic socket insert, any type, each

 

Changes in Code Descriptors

Code New Descriptor Old Descriptor

L3760

 

Elbow orthosis , with adjustable position locking joint(s), prefabricated, item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise Elbow orthosis, with adjustable position locking joint(s), prefabricated, includes fitting and adjustments, any type

 

Medicare Correct Coding Guidelines

Each supplier is ultimately responsible for the HCPCS code(s) they select to bill for the items provided. Resources like code determinations letters and DMECS are useful but many products have not been reviewed. For these un-reviewed products, each supplier must use their best judgment in selecting HCPCS codes for billing. Here are some tips that will help:

  • Check the PDAC Product Classification Lists on DMECS. Although not every HCPCS code has an associated product list, many of the most commonly used codes do.
  • Check the DME MAC publications for coding bulletins and coding guidelines related to products and HCPCS codes for specific information on the item of interest.
  • Refer to the “long” code narrative. All codes have short and long descriptors. The long descriptor often provides more detail regarding the requirements for the code. Select the code with the descriptor that most closely describes the product.
  • Most code narratives are written broadly to be all-inclusive. You may not find a specific code that perfectly matches a product. Use the code that most closely describes the item rather than a NOC (not otherwise classified) or miscellaneous code.
  • Local Coverage Determination related Policy Articles often have additional information in the Coding Guidelines section. Coding guidelines provide additional information on the characteristics of products that meet a specific HCPCS code.
  • Remember that price and fees are NOT part of correct coding. Selecting a code based upon the fee schedule almost always results in an incorrect coding determination. HCPCS codes describe the product not the price.
  • Check with the PDAC. The PDAC Contact Center can provide information that will assist you in code selection. This assistance, however, is NOT considered a formal product review. The advice provided is not an official code determination.  Items are not added to the DMECS Product Classification List based on a query to the PDAC Contact Center.
  • Request that manufacturers submit their products for coding. Although some HCPCS codes require mandatory product review in order to use the code, for most codes product review is voluntary. Many manufacturers are responsive to their customer’ requests for verified HCPCS coding.

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:

  • 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 and K0903, 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 and L1852.
  • AFOs:  A prefabricated multiligamentous support described by code L1906.
  • Lower Limb Prostheses: A microprocessor ankle-foot system with power assist described by code L5969
  • Miscellaneous: A cervical collar described by code L0174 and a functional electric stimulator described by code E0770.

Claims for the above items will be denied if the items have not been reviewed by the PDAC and placed on the PDAC’s Product Classification List.