Retired - L1690 Prefabricated Bilateral Lumbo-sacral Hip Orthosis - Correct Coding

Joint DME MAC & PDAC Publication

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have noticed a substantial increase in claim submission for L1690 (COMBINATION, BILATERAL, LUMBO-SACRAL, HIP, FEMUR ORTHOSIS PROVIDING ADDUCTION AND INTERNAL ROTATION CONTROL, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT). The DME MACs and the Pricing, Data Analysis and Coding (PDAC) Contractor are providing this article to educate suppliers to correctly code products which are described by this L-code.

The products described by L1690 have, at a minimum, the following characteristics of the predicate product which was the Sitting, Walking and Standing Hip Orthotic device (S.W.A.S.H.) (ALLARD International).

• Product is prefabricated and includes fitting and adjustment
• Product contains left and right hip joints specialized for combined planar motion
• Each hip joint uses rigid connectors for attachment to a rigid lumbo-sacral component to maintain therapeutic alignment
• Rigid lumbo-sacral component wraps around the posterior pelvis, includes anterior closures
• Lumbo-sacral component extends from the distal sacrum to L2/L3
• Hip joints align the femurs in abducted posture, set by supplier
• Each thigh cuff attaches to the rigid distal upright of each hip joint, includes closures
• Product may be worn when seated and during ambulation

The orthosis includes fitting and adjustment at the time of delivery. L1690 is a complete product. It is inherent in the definition of “prefabricated” that a particular item is complete. Custom-fabricated additions are only appropriate for custom-fabricated base orthotics and will be therefore denied as incorrect coding, if billed with the L1690 prefabricated orthosis.

Prefabricated devices that require more than minimal self-adjustment for proper use and fit are referred to as custom fitted. More than minimal self-adjustment means that at the time of delivery, the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations that require the expertise of a certified orthotist or an individual who has specialized training in the provision of an orthosis to fit the item to the individual beneficiary.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website.