Correct use of Not Otherwise Specified L-codes for Orthoses and Prostheses - Billing Reminder - JD DME

Joint DME MAC Article
Posted 10/22/20

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and Pricing, Data Analysis and Coding (PDAC) Contractor want to remind suppliers on the correct use of a group of L-codes which share the phrase, "Not otherwise specified" (NOS). This group of codes is commonly referred to as NOC codes. This article will review the group of L-codes specifically for Orthoses and Prostheses. The following is the list of relevant codes:

L0999 (Addition to spinal orthosis, not otherwise specified),
L1499 (Spinal orthosis, not otherwise specified)
L2999 (Lower extremity orthoses, not otherwise specified)
L3649 (Orthopedic shoe, modification, addition or transfer, not otherwise specified)
L3999 (Upper limb orthosis, not otherwise specified)
L5999 (Lower extremity prosthesis, not otherwise specified)
L7499 (Upper extremity prosthesis, not otherwise specified)
L8499 (Unlisted procedure for miscellaneous prosthetic services)

Use of NOC code

Each supplier is ultimately responsible for the HCPCS code they select to bill for the item provided to the beneficiary. Resources such as LCDs, LCD-related Policy Articles, DME MAC articles, code determinations letters and DMECS are useful; but many products currently on the market have not been reviewed. For these un-reviewed products, suppliers are encouraged to check with the PDAC Contact Center (see below for PDAC contact information), which can provide information that will assist in correct code selection.

When the supplier decides there isn’t a specific L-Code(s) which fully describe the provided item, the supplier may consider a NOC type of L-code. In general, a NOC L-code is intended to describe a unique product which is not described by a specific L-code(s). Therefore, the NOC code must not be used to bill for any features or functions already included in one or more L-codes. Examples (not all-inclusive) of items not to be billed with a NOC would be equipment or supplier time used in the fabrication, modification, or delivery.

The NOC codes are divided up and should be used for products within the broad code narrative. Spinal brace products have two NOC code options. L0999 is for an addition to a spinal product whereas L1499 would describe a complete spinal product. The remaining codes can be used to describe a complete product not included in the functions or features of another code.

Suppliers are reminded to consult the Product Classification List (PCL) provided by the PDAC contractor. The list provides code verification of those products which require mandatory code verification and those products submitted voluntarily. Either submission status (mandatory or voluntary) does not allow supplier discretion over the binding assigned code(s). The use of any code, NOC or specific, not assigned to the product is incorrect coding, unbundling.

Not Otherwise Classified (NOC) BILLING INFORMATION

Items billed with any HCPCS code with a narrative description that indicates miscellaneous, NOC, unlisted, or non-specified, must also include the following information in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form:

• Description of the item or service
• Manufacturer name
• Product name and number
• Supplier Price List (PL) amount
• HCPCS code of related item (if applicable)

Miscellaneous HCPCS codes billed without this information will be rejected and will need to be resubmitted with the missing information included.

NOC codes per type

Spinal Orthoses

L0999 (Addition to spinal orthosis, not otherwise specified),
L1499 (Spinal orthosis, not otherwise specified)

Lower Limb Orthoses

L2999 (Lower extremity orthoses, not otherwise specified)

Orthopedic Footwear

L3649 (Orthopedic shoe, modification, addition or transfer, not otherwise specified)

Upper Limb Orthoses

L3999 (Upper limb orthosis, not otherwise specified)

Lower Limb Prostheses

L5999 (Lower extremity prosthesis, not otherwise specified)

Upper Limb Prostheses

L7499 (Upper extremity prosthesis, not otherwise specified)

Miscellaneous Prosthetic Services

L8499 (Unlisted procedure for miscellaneous prosthetic services)

Please do not submit a written request or contact the respective DME MAC’s Provider Call Center to inquire if the description is appropriate for payment. We cannot determine if the comment is sufficient for payment without viewing the entire claim.

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 Contact Center at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET.

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