Code Verification Review Requirement for Lower Limb Orthoses (L1832, L1833, and L1851) and Lumbar Sacral Orthoses (L0648 and L0650) - JA DME

Joint DME MAC and PDAC Publication
Posted March 31, 2022

Recently CMS published updates to the Master List and the selection of certain lower limb orthoses and lumbar sacral orthoses were added to the Required Prior Authorization List of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Items that require prior authorization as a condition of payment (Federal Register / Vol. 87, No. 9, 2051-2058). Within the list of L-codes, two lumbar sacral orthoses codes and three lower limb orthoses codes are scheduled for implementation:

Lumbar Sacral Orthoses:

L0648 - Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to t-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

L0650 - Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panel(s), 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, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Lower Limb Orthoses (Knee Orthoses):

L1832 - Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1833 - Knee orthosis, adjustable knee joints (unicentric or polycentric), positional orthosis, rigid support, prefabricated, off-the shelf

L1851 - Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated, off-the-shelf

The CMS Internet Only Manual (IOM), Publication 100-08, PIM, Chapter 3, Sections 3.3.B and 3.6.2.4 specify that for Medicare claims, only the CMS and the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have the authority to establish HCPCS Level II Coding Guidelines. Pursuant to 42 CFR §§ 414.40 and 45 CFR §§ 162.1002, CMS has the authority to assign and manage HCPCS codes (create, delete, change code narrative etc.).

Correct HCPCS coding is a determination that the item provided to a beneficiary is billed using the appropriate HCPCS code. Suppliers are required to correctly code for the item billed. An item/service is correctly coded when it meets all the coding guidelines listed in the CMS HCPCS guidelines, Local Coverage Determinations (LCDs), LCD-related Policy Articles, or DME MAC articles.

The DME MACs have previously provided Coding Guidelines for these five L-codes; they can be found in the LCD-related Policy Articles Spinal Orthoses (A52500) and Knee Orthoses (A52465). Code Verification for the lumbar sacral orthoses (L0648 and L0650) became effective for claims with dates of service on or after July 1, 2010. The DME MACs are issuing a Coding Verification Requirement for L1832, L1833, and L1851 effective for claims with dates of service on or after 10/10/2022.

The only products which may be billed using codes L0648, L0650, L1832, L1833, and L1851 are those for which a written Coding Verification Review has been made by the Pricing, Data Analysis and Coding (PDAC) Contractor and subsequently published on the appropriate Product Classification List. Products currently assigned (L0648, L0650, L1832, L1833, and L1851) and published on the PDAC Product Classification List do not need to be reverified.

Additional Coding Guidelines

Refer to the Spinal Orthoses Local Coverage Determination, the related Policy Article and the Knee Orthoses Local Coverage Determination, the related Policy Article for additional information on coverage, coding, and documentation for the orthoses.

Correct coding is an essential element for correct claim payment. The PDAC contractor maintains a variety of resources to assist suppliers in determining the appropriate code for Medicare billing. For questions about correct coding, contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 am to 5:00 pm 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 PDAC website for email, FAX, or postal mail information.

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