RETIRED - Correct Coding of Elbow, Shoulder, Shoulder-Elbow-Wrist-Hand and Shoulder- Elbow-Wrist-Hand-Finger Braces (Orthoses) - JA DME

DME MAC & PDAC Joint Publication
Posted November 18, 2021

Based on recent analysis of claims submitted to the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for upper extremity 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.

The Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Sections 3.3.B and 3.6.2.4 specify that for Medicare claims, only CMS and the DME MACs have the authority to establish Healthcare Common Procedure Coding System (HCPCS) Level II Coding Guidelines.

Correct HCPCS coding is a determination that the item provided to a beneficiary is billed using the appropriate HCPCS code for that item. 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 CMS HCPCS guidelines, Local Coverage Determinations (LCDs), LCD-related Policy Articles, or DME MAC articles.

Elbow Orthoses

L3702 (ELBOW ORTHOSIS, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a custom fabricated static positional orthosis that extends from the forearm to the middle humerus.  This is a complete device and no add-on codes may be billed for this orthosis.

L3710 (ELBOW ORTHOSIS, ELASTIC WITH METAL JOINTS, PREFABRICATED, OFF-THE-SHELF) describes a prefabricated OTS orthosis that extends from the forearm to mid-humerus with any type joints on both sides of the elbow. This is a complete device and no add-on codes may be billed for this orthosis.

L3720 (ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, FREE MOTION, CUSTOM FABRICATED) describes a dynamic custom fabricated orthosis with rigid or semi-rigid cuffs that extends from forearm to mid-humerus with free motion joints on both sides of the elbow. This is a complete device and no add-on codes may be billed for this orthosis.

L3730 (ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, EXTENSION/ FLEXION ASSIST, CUSTOM FABRICATED) describes a dynamic custom fabricated orthosis with rigid or semi-rigid cuffs and double uprights that extends from the forearm to mid-humerus. The orthosis has any type extension/flexion control joints that must have a minimum of 15 degrees of adjustability. This is a complete device and no add-on codes may be billed for this orthosis.

L3740 (ELBOW ORTHOSIS, DOUBLE UPRIGHT WITH FOREARM/ARM CUFFS, ADJUSTABLE POSITION LOCK WITH ACTIVE CONTROL, CUSTOM FABRICATED) describes a dynamic custom fabricated orthosis with rigid or semi-rigid cuffs and double uprights and cuffs that extends from the forearm to the wrist with any type adjustable joints that must have a minimum of 15 degrees of adjustability. The brace includes a shoulder harness assembly with a cable to activate the elbow lock. This is a complete device and no add-on codes may be billed for this orthosis.

L3760 (ELBOW ORTHOSIS (EO), WITH ADJUSTABLE POSITION LOCKING JOINT(S), PREFABRICATED, ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE)
describes a dynamic prefabricated custom fitted orthosis with rigid or semi-rigid cuffs and double uprights, that extends from the forearm to mid-humerus.  The orthosis has any type extension/flexion control joint(s) that must have a minimum of 15 degrees of adjustability, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3761 (ELBOW ORTHOSIS (EO), WITH ADJUSTABLE POSITION LOCKING JOINT(S), PREFABRICATED, OFF-THE-SHELF) describes a prefabricated OTS orthosis with rigid or semi-rigid cuffs that extends from the forearm to mid-humerus with any type positioning joints on both sides of the elbow that must have a minimum of 15 degrees of adjustability, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3762 (ELBOW ORTHOSIS (EO), RIGID, WITHOUT JOINTS, INCLUDES SOFT INTERFACE MATERIAL, PREFABRICATED, OFF-THE-SHELF) describes a static rigid prefabricated OTS orthosis that extends from the forearm to mid-humerus, includes soft interface and any type straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3763 (ELBOW WRIST HAND ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a rigid static custom fabricated orthosis that extends from the humerus to the to the metacarpals, includes soft interface and any type straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3764 (ELBOW WRIST HAND ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a dynamic custom fabricated orthosis that extends from the humerus to the metacarpals, includes any type supportive non-torsion joints connected to bars, elastic bands, turnbuckles used to support the elbow wrist and hand, includes soft interface and any type straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3765 (ELBOW WRIST HAND FINGER ORTHOSIS, RIGID, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a static custom fabricated orthosis that extends from the humerus to the phalanges, includes soft interface and any type straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3766 (ELBOW WRIST HAND FINGER ORTHOSIS, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a dynamic custom fabricated orthosis that extends from the humerus to the phalanges. The device may include supportive non-torsion joints connected to bars, elastic bands with outriggers, includes soft interface and any type straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

Shoulder Orthoses

L3650 (SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, PREFABRICATED, OFF-THE-SHELF) describes a prefabricated OTS shoulder brace designed to support the clavicle from limiting motion of the shoulder joint complex. This is a complete device and no add-on codes may be billed for this orthosis.

L3660 (SHOULDER ORTHOSIS, FIGURE OF EIGHT DESIGN ABDUCTION RESTRAINER, CANVAS AND WEBBING, PREFABRICATED, OFF-THE-SHELF) describes a prefabricated OTS shoulder brace designed to support the clavicle from limiting motion of the shoulder joint complex uses a canvas or webbing waist band and humeral band. This is a complete device and no add-on codes may be billed for this orthosis.

L3670 (SHOULDER ORTHOSIS, ACROMIO/CLAVICULAR (CANVAS AND WEBBING TYPE), PREFABRICATED, OFF-THE-SHELF) describes a prefabricated OTS product designed to support and immobilize the shoulder in multiple planes using a swathe and sling design.  Product is made primarily made of canvas and webbing type materials. This is a complete device and no add-on codes may be billed for this orthosis.

L3671 (SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a static custom fabricated shoulder orthosis that extends from the top of the shoulder to above the elbow. The device is completely circumferential of the humeral bone and is used for support of the should joint, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3674 (SHOULDER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITH OR WITHOUT NONTORSION JOINT/TURNBUCKLE, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a static custom fabricated shoulder "airplane design" abduction orthosis. Product may include adjustable rigid cuffs and joints/components to optimize the shoulder angle in multiple planes. Shoulder position is capable of 90 degrees abduction from torso in a fixed position. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm component. It is used for abducting the arm away from the body and capable of immobilizing the shoulder, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3675 (SHOULDER ORTHOSIS, VEST TYPE ABDUCTION RESTRAINER, CANVAS WEBBING TYPE OR EQUAL PREFABRICATED, OFF-THE-SHELF) describes an OTS prefabricated shoulder orthosis which abducts and immobilizes the shoulder joint in a canvas vest type device. Included in the code are closures from lacing, webbing, hook and loop, or equal, and additional support strapping. This is a complete device and no add-on codes may be billed for this orthosis.

L3677 (SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE) describes a prefabricated custom fitted shoulder orthosis with rigid chest, arm, limited motion shoulder components which combine to restrict shoulder from subluxation. Restricted motion of shoulder is typically with abduction, retraction, and rotation. The device can be unilateral or bilateral. Device includes soft interface and any type straps and closures and there are no additional add-on codes for this orthosis. The predicate product is the Shoulder Subluxation Inhibitor (Boston Brace International, Inc.). This is a complete device and no add-on codes may be billed for this orthosis.

L3678 (SHOULDER ORTHOSIS, SHOULDER JOINT DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, PREFABRICATED, OFF-THE-SHELF) describes a prefabricated OTS shoulder orthosis with rigid chest, arm, limited motion shoulder components which combine to restrict shoulder from subluxation.  Restricted motion of shoulder is typically with abduction, retraction, and rotation. The device can be unilateral or bilateral. Device includes soft interface and any type straps and closures and there are no additional add-on codes for this orthosis. The predicate product is the Shoulder Subluxation Inhibitor (Boston Brace International, Inc.). This is a complete device and no add-on codes may be billed for this orthosis.

Shoulder-Elbow-Wrist-Hand Orthoses

L3960 (SHOULDER-ELBOW-WRIST-HAND ORTHOSIS, (SEWHO), ABDUCTION POSITIONING, AIRPLANE DESIGN, PREFABRICATED, INCLUDED FITTING AND ADJUSTMENT) describes a prefabricated custom fitted shoulder "airplane design" abduction orthosis which includes the elbow wrist hand and fingers. There are adjustable rigid cuffs and joints/components to optimize the shoulder, elbow, wrist, and hand angles. Shoulder position is capable of 90 degrees abduction from torso. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm components. Product is all-inclusive of soft interface and closures/straps. It is used for abducting the arm away from the body and capable of immobilizing the shoulder, elbow, wrist, and hand. This is a complete device and no add-on codes may be billed for this orthosis.

L3961 (SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a static custom fabricated orthosis that extends from the top of the shoulder to the metacarpals, includes soft interface and straps. Product is all-inclusive of soft interface and closures/straps. This is a complete device and no add-on codes may be billed for this orthosis.

L3962 (SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING, ERB'S PALSY DESIGN, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a dynamic prefabricated custom fitted shoulder orthosis which includes the elbow wrist hand and fingers. There are rigid cuffs with an extension to optimize the shoulder, elbow, wrist and hand angles.  Shoulder position is capable of 90 degrees abduction from torso. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm components. Product is all-inclusive of soft interface and closures/straps. It is used for positioning the shoulder in abduction, external rotation, elbow extension, with forearm supination and extension of wrist and fingers. Product is all-inclusive of soft interface and closures/straps. This is a complete device and no add-on codes may be billed for this orthosis.

L3967 (SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a static custom fabricated shoulder "airplane design" abduction orthosis which includes the elbow wrist hand and fingers. There are rigid cuffs with an extension to optimize the shoulder, elbow, wrist and hand angles. Shoulder position is capable of 90 degrees abduction from torso. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm components. Product is all-inclusive of soft interface and closures/straps. It is used for abducting the arm away from the body and capable of immobilizing the shoulder, elbow, wrist, and hand. Product is all-inclusive of soft interface and closures/straps. This is a complete device and no add-on codes may be billed for this orthosis.

L3971 (SHOULDER ELBOW WRIST HAND ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a dynamic custom fabricated shoulder orthosis that extends from the top of the shoulder to the phalanges, includes supportive non-torsion joints, elastic bands, turnbuckles, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3973 (SHOULDER ELBOW WRIST HAND ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes dynamic static custom fabricated shoulder "airplane design" abduction orthosis which includes the elbow wrist hand and fingers. There are rigid cuffs with an extension to optimize the shoulder, elbow, wrist and hand angles. Shoulder position is capable of 90 degrees abduction from torso. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm components. It is used for abducting the arm away from the body and capable of immobilizing the shoulder, elbow, wrist, and hand, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

Shoulder-Elbow-Wrist-Hand-Finger Orthoses

L3975 (SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a static custom fabricated shoulder orthosis that extends from the top of the shoulder to the phalanges.  This is a complete device and no add-on codes may be billed for this orthosis.

L3976 (SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, WITHOUT JOINTS, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a static custom fabricated shoulder "airplane design" abduction orthosis which includes the elbow wrist hand and fingers. There are rigid cuffs with an extension to optimize the shoulder, elbow, wrist and hand angles. Shoulder position is capable of 90 degrees abduction from torso. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm components. It is used for abducting the arm away from the body and capable of immobilizing the shoulder, elbow, wrist, and hand, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3977 (SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, SHOULDER CAP DESIGN, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a dynamic custom fabricated shoulder orthosis that extends from the top of the shoulder and extends to wrist, hand and finger joints, elastic bands or supportive non-torsion turnbuckles, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

L3978 (SHOULDER ELBOW WRIST HAND FINGER ORTHOSIS, ABDUCTION POSITIONING (AIRPLANE DESIGN), THORACIC COMPONENT AND SUPPORT BAR, INCLUDES ONE OR MORE NONTORSION JOINTS, ELASTIC BANDS, TURNBUCKLES, MAY INCLUDE SOFT INTERFACE, STRAPS, CUSTOM FABRICATED, INCLUDES FITTING AND ADJUSTMENT) describes a dynamic custom fabricated shoulder "airplane design" abduction orthosis which includes the elbow wrist hand and fingers. There are rigid cuffs with an extension to optimize the shoulder, elbow, wrist and hand angles. Shoulder position is capable of 90 degrees abduction from torso. Adjustable rigid chest and pelvic frames or panels supports shoulder and arm components. It is used for abducting the arm away from the body and capable of immobilizing the shoulder, elbow, wrist, and hand, includes soft interface, straps and closures. This is a complete device and no add-on codes may be billed for this orthosis.

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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