Coding Issues

2021 HCPCS Code Updates

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

  • K1014 -Addition, endoskeletal knee-shin system, 4 bar linkage or multiaxial, fluid swing and stance phase control (effective April 1, 2021)
  • K1015-Foot, adductus positioning device, adjustable (effective April 1, 2021)
  • K1022- Addition to lower extremity prosthesis, endoskeletal, knee disarticulation, above knee, hip disarticulation, positional rotation unit, any type (effective October 1, 2021)

 Coding Guidelines for Upper Extremity Orthoses

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Pricing, Data Analysis and Coding (PDAC) contractor released correct coding reminders for Elbow, Shoulder-Elbow-Wrist-Hand and Shoulder-Elbow-Wrist-Hand-Finger Orthoses; and Finger, Hand, Hand-Finger, and Wrist-Hand-Finger Orthoses.

Coding Verification for Articulating Digit(s) and Prosthetic Hands

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 L6715 and L6880. Effective for claims with dates of service on or after January 1, 2022, the only products which may be billed using codes L6715 and L6880 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 DME MACs and PDAC also released revised correct coding guidelines for articulating digit(s) and prosthetic hands here.

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.

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.