Retired - Spinal Orthosis – Coding Verification Review Requirement

The Spinal Orthoses: TLSO and LSO policy article published March 11, 2010, contains revised coding guidelines that require certain products to be evaluated by the Pricing, Data Analysis and Coding (PDAC) contractor for proper coding. Coding verification will be required for both prefabricated and custom fabricated products. Products evaluated by the PDAC will be listed on Durable Medical Equipment Coding System (DMECS). Products that do not appear on the Product Classification List on DMECS must be coded A9270. These revised requirements are effective for claims with dates of service on or after July 1, 2010.

Effective for claims with dates of service on or after July 1, 2010, the only products that may be billed using codes L0450, L0454-L0472, L0488-L0492, L0625-L0628, L0630, L0631, L0633, L0635, L0637, and L0639 for prefabricated orthoses are those that are specified in the Product Classification List on the Pricing, Data Analysis, and Coding (PDAC) contractor web site.

There are two categories of custom fabricated spinal orthoses (codes L0452, L0480-L0486, L0629, L0632, L0634, L0636, L0638, and L0640):

• 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 web site.

• 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 web site 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.

Effective for claims with dates of service on or after July 1, 2010, prefabricated spinal orthoses and spinal orthoses that are custom fabricated by a manufacturer/ central fabrication facility which have not received coding verification review from the PDAC must be billed with code A9270.

To view the updated policy article, please locate the “Spinal Orthoses: TLSO and LSO” Local Coverage Determination (LCD) on the website of any of the 4 DME MACs. The updated policy article is linked to the LCD.

For coding questions regarding this change, please call the PDAC Contact Center at (877) 735-1326 Monday through Friday from 8:30 a.m. to 4 p.m. CT or email using the PDAC Email Contact form located at https://www.dmepdac.com. For questions concerning the Spinal Orthoses TLSO and LSO policy, or questions concerning this policy change, please contact your local DME MAC.