Orthoses - Replacement of Components Clarification - Republished - JA DME

Originally Published December 2003

Updated July 10, 2014

The allowance for a prefabricated orthoses includes all components provided at the time of initial issue including, but not limited to, soft interfaces, straps, closures, etc. Replacements of components of covered orthoses are covered if the original component is no longer functional due to wear and cannot be repaired. Replacement components (e.g., soft interfaces) that are provided on a routine basis, without regard to whether the original item is worn out, are not covered.

Some replacement items have unique HCPCS codes. For example, replacement soft interfaces used with ankle contracture orthoses or foot drop splints are billed with HCPCS codes L4392 and L4394, respectively. One unit of service of the replacement interface HCPCS code is covered no more often than once every 6 months. Replacement components that do not have a unique HCPCS code must be billed with a "not otherwise specified" code - L1499, L2999, or L3999, whichever is applicable. The claim must include a description of the component provided, the reason for replacement, and the HCPCS code or narrative description of the base orthosis.

Note: HCPCS codes L4040-L4055 do not describe replacement soft interfaces used with contracture orthoses.

For questions about correct coding, contact the Pricing, Data Analysis, and Coding (PDAC) Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form located on the PDAC website: https://www.dmepdac.com/.