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

 

Last Updated Wed, 22 Jul 2020 18:38:26 +0000