Scoliosis Brace - Correct Coding - JA DME
Scoliosis Brace - Correct Coding
DME MAC and PDAC Joint Publication
Based on recent analysis of claims submitted to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for scoliosis braces, the DME MACs and the Pricing, Data Analysis and Coding (PDAC) Contractor want to remind DMEPOS suppliers about the correct coding for these products.
There are 5 base Healthcare Common Procedure Codes (HCPCS) available to fully describe scoliosis braces.
Base Codes
L1000 CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL
L1005 TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND ADJUSTMENT
L1200 THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY
L1300 OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT MODEL
L1310 OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET
Three codes - L1005, L1300, L1310- are all inclusive and are not billed with addition codes.
Two codes - L1000, L1200 - have specific addition codes which can be used to describe components utilized to support or resist the progression of the user’s specific spinal curve pattern (see section on addition codes below).
Base Code and Addition Codes
L1000 (CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL)
The following table lists addition codes which describe components or features that can be physically incorporated into the L1000 custom fabricated base orthosis but are not considered to be included in the allowance for the L1000 orthosis. These addition codes will be denied as not separately payable if billed without the related base code, L1000.
| Code | Description |
|---|---|
| L1010 | ADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) OR SCOLIOSIS ORTHOSIS, AXILLA SLING |
| L1020 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD |
| L1025 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATING |
| L1030 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR BOLSTER PAD |
| L1040 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR OR LUMBAR RIB PAD |
| L1050 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PAD |
| L1060 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PAD |
| L1070 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLING |
| L1080 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER |
| L1085 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER, BILATERAL WITH VERTICAL EXTENSIONS |
| L1090 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR SLING |
| L1100 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER |
| L1110 | ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER, MOLDED TO PATIENT MODEL |
| L1120 | ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, COVER FOR UPRIGHT, EACH |
L1200 (THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY)
The following table lists addition codes which describe components or features that can be physically incorporated into the L1200 orthosis but are not considered to be included in the allowance for the L1200 orthosis. These addition codes will be denied as not separately payable if billed without the related base code, L1200.
| Code | Description |
|---|---|
| L1210 | ADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSION |
| L1220 | ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSION |
| L1230 | ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTURE |
| L1240 | ADDITION TO TLSO, (LOW PROFILE), LUMBAR DEROTATION PAD |
| L1250 | ADDITION TO TLSO, (LOW PROFILE), ANTERIOR ASIS PAD |
| L1260 | ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC DEROTATION PAD |
| L1270 | ADDITION TO TLSO, (LOW PROFILE), ABDOMINAL PAD |
| L1280 | ADDITION TO TLSO, (LOW PROFILE), RIB GUSSET (ELASTIC), EACH |
| L1290 | ADDITION TO TLSO, (LOW PROFILE), LATERAL TROCHANTERIC PAD |
HCPCS codes L1005, L1300 and L1310 are considered all-inclusive. The use of addition codes with these three codes will be considered incorrect coding (unbundling).
The use of L0999 (ADDITION TO SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED) or L1499 (SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED) must not be used to bill for any features or functions included in the base code nor should it be used when a specific L-code exists. Use of these two codes is incorrect coding (unbundling).
If you have questions, please contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday. You may also visit the website to chat with one of the representatives or select the Contact Us button at the top of the page for email, FAX or postal mail information.
Publication History
| Date of Change | Description |
|---|---|
| 07/23/20 | Originally Published |
