Orthoses/Prostheses - Coding for Professional Services/Fabrication Supplies - Republished

Originally Published September 2004

Updated July 10, 2014

HCPCS codes L4205 (Repair of orthotic device, labor component, per 15 minutes) and L7520 (Repair of prosthetic device, labor component, per 15 minutes) may only be billed for time involved with the actual repair of an orthosis or prosthesis, respectively, or for medically necessary adjustments made more than 90 days after delivery.

HCPCS codes L4205 and L7520 must not be used to bill for time involved with other professional services including, but not limited to:

  • Evaluating the patient
  • Taking measurements, making a cast, making a model, use of CAD/CAM
  • Making modifications to a prefabricated item to fit it to the individual patient
  • Follow-up visits
  • Making adjustments at the time of or within 90 days after delivery

Reimbursement for these services is included in the allowance for the HCPCS codes which describe the orthosis/prosthesis.

Similarly, HCPCS codes L4210 (Repair of orthotic device, repair or replace minor parts) and L7510 (Repair of prosthetic device, repair or replace minor parts) must not be used for casting supplies or other materials used in the fitting or fabrication of an orthosis/prosthesis.

If a supplier decides to submit a claim for services/items that are included in the allowance for the orthosis/prosthesis, HCPCS code L9900 (Orthotic and prosthetic supply, accessory and/or service component of another HCPCS L code) must be used. HCPCS code L9900 is denied as not separately payable.

Services or supplies associated with the provision of plaster or fiberglass casts or splints are in the jurisdiction of the local carriers and fiscal intermediaries. Claims for these items may not be submitted to the DME MAC.

Last Updated Fri, 04 Nov 2016 13:11:01 +0000