Spinal Orthoses—Coding Verification Review Requirement

The Spinal Orthoses: TLSO and LSO policy article - Effective July 2010 published 3/11/2010 contains revised coding guidelines requiring certain products to be evaluated by the 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 the PDAC DMECS Web site at www.dmepdac.com/dmecsapp/do/search. Products that do not appear in the DMECS Product Classification List must be coded A9270. These revised requirements are effective for claims with dates of service on or after 7/1/2010.

The Coding Guidelines section of the policy article states:

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 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 7/1/2010, 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.

Refer to the complete local coverage determination and policy article for additional information.