By Sean Peterson, AOPA Government Affairs Department

In O&P, staying current on all L code changes is vital. New, deleted and modified codes went into effect on Jan. 1, 2007, and the previous 90-day grace period for billing old codes is no longer allowed.
As soon as the 2007 codes were released, AOPA staff reviewed the list closely and identified any modifications. Below is a list, with explanation, of all new codes, deleted codes and changes to code descriptors.

As of press time, fees for the new codes had not yet been released. As soon as they are released, AOPA will notify you via the Almanac’s “In the News” section and AOPA In Advance, AOPA’s electronic members-only newsletter.

What do the codes mean?
L codes describe O&P services, and are updated once a year. Most of the codes in this list are L codes. A codes, also present in this list, represent medical and surgical supplies.

S codes and K codes are temporary codes and can represent any type of device.

New codes
CMS has introduced 23 new codes. They will go into effect for dates of service on or after Jan. 1, 2007.
Nine result from its decision to consolidate upper-extremity terminal device codes from ones that included specific brand names in their descriptors to ones that represent general categories:

L6703	Terminal device, passive hand/mitt, any material, any size
L6704	Terminal device, sport/recreational/work attachment, any material, any size
L6706	Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined
L6707	Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined
L6708	Terminal device, hand, mechanical, voluntary opening, any material, any size
L6709	Terminal device, hand, mechanical, voluntary closing, any material, any size
L7007	Electric hand, switch or myoelectric controlled, adult
L7008	Electric hand, switch or myoelectric controlled, pediatric
L7009	Electric hook, switch or myoelectric controlled, adult

CMS also introduced new codes to describe heavy-duty additions to the knee, foot or elbow of the prosthetic device.

L5993	Addition to lower extremity prosthesis, heavy-duty feature, foot only (for patient weight greater than 300 lbs.)
L5994	Addition to lower extremity prosthesis, heavy-duty feature, knee only (for patient weight greater than 300 lbs.)
L6639	Upper extremity addition, heavy-duty feature, any elbow

CMS introduced new A codes to describe protective helmets formerly coded as L0100 or L0110:

A8000	Helmet, protective, soft, prefabricated, includes all components and accessories
A8001	Helmet, protective, hard, prefabricated, includes all components and accessories
A8002	Helmet, protective, soft, custom fabricated, includes all components and accessories
A8003	Helmet, protective, hard, custom fabricated, includes all components and accessories
A8004	Soft interface for helmet, replacement only

CMS also introduced the following codes:

L1001	Cervical thoracic lumbar sacral orthosis, immobilizer, infant size, prefabricated, includes fitting and adjustments
L3860	Wrist hand finger orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface material, straps, custom fabricated, includes fitting and adjustment
L3808	Wrist hand finger orthosis, rigid without joints, may include soft interface material, straps, custom fabricated, includes fitting and adjustment
L3915	Wrist hand orthosis, includes one or more nontorsion joint(s), elastic bands, turnbuckles, may include soft interface, straps, prefabricated, includes fitting and adjustment
L6611	Addition to upper extremity prosthesis, external-powered, additional switch, any type
L6624	Upper extremity addition, flexion/extension and rotation wrist unit

Deleted codes
CMS deleted 49 codes. As discussed previously, L0100 and L0110 were crosswalked, or changed to new A codes for describing protective helmets that have the same descriptors:

L0100	Cranial orthosis (helmet), with or without soft interface, molded to patient model
L0110	Cranial orthosis (helmet), with or without soft interface, non-molded

Since L3914 and L3908 had almost identical descriptors and described the same function, CMS also eliminated L3914:

L3914

Wrist hand orthosis, wrist extension cock-up, prefabricated, includes fitting/adjustment

It also deleted all upper extremity terminal device codes that referenced specific brand names:

L6700	Terminal device, hook, Dorrance or equal, model #3
L6705	Terminal device, hook, Dorrance or equal, model #5
L6710	Terminal device, hook, Dorrance or equal, model #5X
L6715	Terminal device, hook, Dorrance or equal, model #5XA
L6720	Terminal device, hook, Dorrance or equal, model #6
L6725	Terminal device, hook, Dorrance or equal, model #7
L6730	Terminal device, hook, Dorrance or equal, model #7LO
L6735	Terminal device, hook, Dorrance or equal, model #8
L6740	Terminal device, hook, Dorrance or equal, model #8X
L6745	Terminal device, hook, Dorrance or equal, model #88X
L6750	Terminal device, hook, Dorrance or equal, model #10P
L6755	Terminal device, hook, Dorrance or equal, model #10X
L6765	Terminal device, hook, Dorrance or equal, model #12P
L6770	Terminal device, hook, Dorrance or equal, model #99X
L6775	Terminal device, hook, Dorrance or equal, model #555
L6780	Terminal device, hook, Dorrance or equal, model #SS555
L6790	Terminal device, hook, Accu hook or equal
L6795	Terminal device, hook, 2 load or equal
L6800	Terminal device, hook, APRL VC or equal
L6806	Terminal device, hook, TRS grip, grip III, VC or equal
L6807	Terminal device, hook, grip I, grip II, VC or equal
L6808	Terminal device, hook, TRS Adept, infant or child, VC or equal
L6809	Terminal device, hook, TRS Super Sport, passive
L6825	Terminal device, hand, Dorrance, VO
L6830	Terminal device, hand, APRL, VCv
L6835	Terminal device, hand, Sierra, VO
L6840	Terminal device, hand, Becker Imperial
L6845	Terminal device, hand, Becker Lock Grip
L6850	Terminal device, hand, Becker Plylite
L6855	Terminal device, hand, Robin-Aids, VO
L6860	Terminal device, hand, Robin-Aids, VO soft
L6865	Terminal device, hand, passive hand
L6867	Terminal device, hand, Detroit infant hand (mechanical)
L6868	Terminal device, hand, passive infant hand (Steeper, Hosmer or equal)
L6870	Terminal device, hand, child mitt
L6872	Terminal device, hand, NYU child hand
L6873	Terminal device, hand, mechanical infant hand (Steeper or equal)
L6875	Terminal device, hand, Bock, VC
L6880	Terminal device, hand, Bock, VO
L7010	Electronic hand, Otto Bock, Steeper or equal, switch controlled
L7015	Electronic hand, System Teknik, Variety Village or equal, switch controlled
L7020	Electronic Greifer, Otto Bock or equal, switch controlled
L7025	Electronic hand, Otto Bock or equal, myoelectric controlled
L7030	Electronic hand, System Teknik, Variety Village or equal, myoelectric controlled
L7035	Electronic Greifer, Otto Bock or equal, myoelectric controlled

The following code was also deleted:

L3902

Wrist hand finger orthosis, external powered, compressed gas, custom-fabricated

Changes in code descriptors
CMS changed the descriptors for 10 codes. Three codes have had their descriptors slightly modified to eliminate references to specific brand names. S1040 now includes the phrase “for pediatric use only,” and L0631 adds the phrase “closures, may include padding, shoulder straps” in order to maintain consistency with other LSO codes.

The table below lists the code, the old descriptor, followed by the new descriptor.

CODE	OLD DESCRIPTOR	NEW DESCRIPTOR
L0361	Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, pendulous abdomen design, prefabricated, includes fitting and adjustment	Lumbar-sacral orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from sacrococcygeal junction to T-9 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, includes fitting and adjustment
L5848	Addition to endoskeletal knee-shin system, hydraulic stance extension, dampening feature, with or without adjustability	Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability
L5995	Addition to lower extremity prosthesis, heavy duty feature, for patient weight greater than 300 lbs	Addition to lower extremity prosthesis, heavy duty feature, other than foot or knee, for patient weight greater than 300 lbs
L6805	Addition to terminal device, modifier wrist flexion unit	Addition to terminal device, modifier wrist unit
L6810	Terminal device, pincher tool, Otto Bock or equal	Addition to terminal device, precision pinch device
L6881	Automatic grasp feature, addition to upper limb prosthetic terminal device	Automatic grasp feature, addition to upper limb electric prosthetic terminal device
L6884	Replacement socket, above elbow disarticulation, molded to patient model, for use with or without external power	Replacement socket, above elbow/elbow disarticulation, molded to patient model, for use with or without external power
L7040	Prehensile actuator, Hosmer or equal, switch controlled	Prehensile actuator, switch controlled
L7045	Electric hook, child, Michigan or equal, switch controlled	Electric hook, switch or myoelectric controlled, pediatric
S1040	Cranial remolding orthosis, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)	Cranial remolding orthosis, pediatric, rigid, with soft interface material, custom fabricated, includes fitting and adjustment(s)

How Does Medicare Determine Allowables? When new codes are added to the Medicare fee schedule, allowable amounts are arrived at by using one of two methods: “crosswalking” or “gap-filling.”  Crosswalking. If there is an existing code which is clinically, technologically, and functionally identical to the new code, CMS will often assign the new code the same allowable amount of the already existing, equivalent code. This is otherwise known as crosswalking. Gap-filling. Technology is constantly changing, especially in O&P. Consequently, many new codes do not have an existing comparable code that could be used to crosswalk allowances. Medicare determines an allowable for a new code in this situation through a process called gap-filling. This method requires each DME MAC to determine the appropriate allowable for the new code.  This is accomplished by first gathering data from various sources, including manufacturers, private insurers who may already pay for the device, provider-submitted charges, and data from various other resources. With this information, a temporary figure is established. But further steps are required in order to determine a final allowable amount. After the DME MAC determines a temporary figure for the new code, it then lowers the amount by a deflation factor until it reaches an estimate of what the allowable amount would have been in 1986/1987. This deflated amount is then inflated based on each year’s annual update to arrive at an allowable for the current year. Why does this occur? The original Medicare fee schedule for O&P, which went into effect on January 1, 1989, was based on data gathered in those years. By law, Medicare is required to use 1986/1987 as the base years when determining new O&P allowables. In an effort to establish a fair reimbursement, CMS has implemented this deflation/inflation process to calculate the current allowable amount for new codes that are not sufficiently similar to already existing codes. With such a complicated process, it is understandable why many new codes do not immediately appear on the Medicare fee schedule with a set allowable amount. However, this does not mean that the new code is any less valid. If a code does not yet have an allowable amount assigned to it, you can still bill using the new code and will be reimbursed based on individual consideration. In this case, you would set the allowable amount based on your charges and prepare to provide documentation if necessary. See the Almanac’s “In the News” section and AOPA In Advance, AOPA’s electronic members-only newsletter, for more information on an increase in the O&P fee schedule.