L1005 - Tension Based Scoliosis Orthosis and Accessory Pads, Includes Fitting and Adjustment - Correct Coding

Joint DME MAC and PDAC Publication

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have noticed a substantial increase in claim submissions for HCPCS code L1005 (TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, 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.

Code L1005 describes a spinal orthosis used to treat scoliosis. The spinal orthosis contains multiple tension features (Tension bands, straps, or pads – not all inclusive) which connect to a semi rigid pelvic structure. The multiple components create tension forces to exert a dynamic force on the torso for resisting the scoliosis curve. This orthosis is designed to control or support against further progression of an adolescent idiopathic scoliosis curve. L1005 is a complete product, as it is inherent in the definition of "prefabricated" that a particular item is complete. Custom-fabricated additions will be denied as incorrect coding if billed with the L1005 prefabricated orthosis, since custom fabricated additions are only appropriate for custom-fabricated base orthotics.

L1005 includes fitting and adjustment at the time of delivery. Devices that are prefabricated and include fitting and adjustment are also referred to as custom fitted. Classification as custom fitted requires more than minimal self-adjustment at the time of delivery in order to provide an individualized fit, i.e., the item must be trimmed, bent, molded (with or without heat), or otherwise modified resulting in alterations beyond minimal self-adjustment. This fitting method at delivery must require 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.