Prior Authorization and Code Verification Review Requirement for Lower Limb Orthoses (L1843, L1845, L1951) and Spinal Orthoses (L0631, L0637, L0639) - JA DME

Joint DME MAC and PDAC Publication
Posted on September 5, 2024

CMS published updates to the Master List and the selection of three spinal orthoses codes and three lower limb orthoses codes 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. 89, No. 93, 41324-41330).

Spinal Orthoses:

L0631 - 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0637 - Lumbar-sacral orthosis, sagittal-coronal control, with rigid anterior and posterior frame/panels, posterior extends from sacrococcygeal junction to t-9 vertebra, lateral strength provided by rigid lateral frame/panels, produces intracavitary pressure to reduce load on intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L0639 - Lumbar-sacral orthosis, sagittal-coronal control, rigid shell(s)/panel(s), posterior extends from sacrococcygeal junction to t-9 vertebra, anterior extends from symphysis pubis to xyphoid, produces intracavitary pressure to reduce load on the intervertebral discs, overall strength is provided by overlapping rigid material and stabilizing closures, includes straps, closures, may include soft interface, pendulous abdomen design, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

Lower Limb Orthoses:

L1843 - 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1845 - Knee orthosis, double 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 item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

L1951 - Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment

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 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 guidance for these nine HCPCS codes; the coding guidance can be found in the following LCD-related Policy Articles: Spinal Orthoses: TLSO and LSO (A52500), Knee Orthoses (A52465), and Ankle-Foot/Knee-Ankle-Foot Orthoses (A52457). Code Verification Requirement for the lumbar sacral orthoses (L0631, L0637 and L0639) became effective for claims with dates of service on or after July 1, 2010, and a Code Verification Review Requirement for Knee orthosis code L1845 became effective for claims with dates of service on or after July 1, 2008. The DME MACs are issuing a Coding Verification Requirement for L1843 and L1951, effective for claims with dates of service on or after December 1, 2024.

The only products which may be billed using codes L1843 and L1951, 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 (L1843 and L1951) and published on the PDAC Product Classification List do not need to be reverified.

Additional Coding Guidelines

For additional information on coverage, coding, and documentation refer to appropriate LCD and the LCD-related Policy Article:

• L1843 - Knee Orthoses LCD (L33318) and the LCD-related Policy Article (A52465)
• L1951 - Ankle-Foot/Knee-Ankle-Foot Orthosis LCD (L33686) and the LCD-related Policy Article (A52457).

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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