The Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Region A has released a new policy article that lists revised coding for spinal orthoses. The article, titled, “Spinal Orthoses: TLSO and LSO – Policy Article – Effective July 2010” contains revised coding guidelines that now require that certain products be evaluated by the Pricing, Data Analysis, and Coding (PDAC) contractor for proper coding. According to the Centers for Medicare and Medicaid Services (CMS), the coding verification will be required for both prefabricated and custom-fabricated products. The products that must be evaluated by the PDAC will be listed on the PDAC Durable Medical Equipment Coding System (DMECS) website.
The Coding Guidelines section of the policy article states the following:
Effective for claims with dates of service on or after July 1, 2010, the only products that may be billed using codes L-0450, L-0454-L-0472, L-0488-L-0492, L-0625-L-0628, L-0630, L-0631, L-0633, L-0635, L-0637, and L-0639 for prefabricated orthoses are those that are specified in the Product Classification List on the PDAC contractor website.
There are two categories of custom-fabricated spinal orthoses (codes L-0452, L-0480-L-0486, L-0629, L-0632, L-0634, L-0636, L-0638, and L-0640):
- Orthoses that are custom fabricated by a manufacturer/central fabrication facility and then sent to someone other than the patient. Effective for claims with dates of service on or after July 1, 2010, these items may be billed using one of these codes only if they are listed in the Product Classification List on the PDAC website.
- Orthoses that are custom fabricated from raw materials and are dispensed directly to the patient by the entity that fabricated the orthosis. These items do not have to be listed on the PDAC website in order to be billed using a custom-fabricated spinal-orthosis code. However, the supplier must provide a list of the materials that were used and a description of the custom-fabrication process on request.
For more information, view the complete Local Coverage Determination.
