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July 23, 2020

Scoliosis Brace – Correct Coding

DME MAC and PDAC Joint Publication

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

There are 5 base Healthcare Common Procedure Codes (HCPCS) available to fully describe scoliosis braces.

Base Codes:

L1000 CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL
L1005 TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND ADJUSTMENT
L1200 THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY
L1300 OTHER SCOLIOSIS PROCEDURE, BODY JACKET MOLDED TO PATIENT MODEL
L1310 OTHER SCOLIOSIS PROCEDURE, POST-OPERATIVE BODY JACKET

Three codes - L1005, L1300, L1310- are all inclusive and are not billed with addition codes. 

Two codes - L1000, L1200 - have specific addition codes which can be used to describe components utilized to support or resist the progression of the user's specific spinal curve pattern (see section on addition codes below).

Base Code and Addition Codes
L1000 (CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) (MILWAUKEE), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS, INCLUDING MODEL)

The following table lists addition codes which describe components or features that can be physically incorporated into the L1000 custom fabricated base orthosis but are not considered to be included in the allowance for the L1000 orthosis. These addition codes will be denied as not separately payable if billed without the related base code, L1000.

L1010

ADDITION TO CERVICAL-THORACIC-LUMBAR-SACRAL ORTHOSIS (CTLSO) OR SCOLIOSIS ORTHOSIS, AXILLA SLING

L1020

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD

L1025

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, KYPHOSIS PAD, FLOATING

L1030

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR BOLSTER PAD

L1040

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR OR LUMBAR RIB PAD

L1050

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, STERNAL PAD

L1060

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, THORACIC PAD

L1070

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, TRAPEZIUS SLING

L1080

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER

L1085

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, OUTRIGGER, BILATERAL WITH VERTICAL EXTENSIONS

L1090

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, LUMBAR SLING

L1100

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER

L1110

ADDITION TO CTLSO OR SCOLIOSIS ORTHOSIS, RING FLANGE, PLASTIC OR LEATHER, MOLDED TO PATIENT MODEL

L1120

ADDITION TO CTLSO, SCOLIOSIS ORTHOSIS, COVER FOR UPRIGHT, EACH

L1200 (THORACIC-LUMBAR-SACRAL-ORTHOSIS (TLSO), INCLUSIVE OF FURNISHING INITIAL ORTHOSIS ONLY)

The following table lists addition codes which describe components or features that can be physically incorporated into the L1200 orthosis but are not considered to be included in the allowance for the L1200 orthosis. These addition codes will be denied as not separately payable if billed without the related base code, L1200.

L1210

ADDITION TO TLSO, (LOW PROFILE), LATERAL THORACIC EXTENSION

L1220

ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC EXTENSION

L1230

ADDITION TO TLSO, (LOW PROFILE), MILWAUKEE TYPE SUPERSTRUCTURE

L1240

ADDITION TO TLSO, (LOW PROFILE), LUMBAR DEROTATION PAD

L1250

ADDITION TO TLSO, (LOW PROFILE), ANTERIOR ASIS PAD

L1260

ADDITION TO TLSO, (LOW PROFILE), ANTERIOR THORACIC DEROTATION PAD

L1270

ADDITION TO TLSO, (LOW PROFILE), ABDOMINAL PAD

L1280

ADDITION TO TLSO, (LOW PROFILE), RIB GUSSET (ELASTIC), EACH

L1290

ADDITION TO TLSO, (LOW PROFILE), LATERAL TROCHANTERIC PAD

HCPCS codes L1005, L1300 and L1310 are considered all-inclusive.  The use of addition codes with these three codes will be considered incorrect coding (unbundling).

The use of L0999 (ADDITION TO SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED) or L1499 (SPINAL ORTHOSIS, NOT OTHERWISE SPECIFIED) must not be used to bill for any features or functions included in the base code nor should it be used when a specific L-code exists.  Use of these two codes is incorrect coding (unbundling).

If you have questions, please contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday. You may also visit the websiteExternal Website to chat with one of the representatives or select the Contact Us button at the top of the page for email, FAX or postal mail information.

Publication History

July 23, 2020

Originally Published

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