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

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.

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.

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).

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.