Navigate the New HCPCS Codes:
2008 HCPCS Code Changes
By Kathy Dodson, AOPA Government Affairs Department
Want your claims process to run smoothly? Keep up to date on changes
to the HCPCS coding system for O&P services. The Centers for
Medicare and Medicaid Services (CMS) recently announced the new codes,
code deletions and code wording changes for 2008, which became
effective on January 1. Unlike times past, there is no longer any grace
period to allow an easy transition between old and new codes. Begin to
use these new codes immediately.
As of press time, the new fee schedule allowances to
accompany these code changes had not been announced. As soon as they
are released, AOPA will publish them in its biweekly newsletter, AOPA
In Advance.
In general, HCPCS codes are updated once a year,
based upon applications submitted by January 1 of the previous year. So
this year’s changes were the result of applications submitted by
January 1 of 2007. There are 11 new codes, 42 deletions and 10 code
descriptor changes for 2008. Here are the specifics.
New codes
The majority of the new codes this year were added
in order to provide a pediatric version of terminal devices. Last year,
the range of codes for terminal devices was greatly reduced and all
pediatric codes were eliminated. Manufacturers worked with SADMERC to
convince it that pediatric codes were still needed for non-Medicare
claims. As a result, these new codes were added. CMS also added several
new codes for wrist/hand/finger devices, to take the place of numerous
old codes that it deleted (see deletions chart below.)
One A code was also added, to allow for coding of
devices that are only used for pressure relief. While this code will
not be covered by Medicare, it may allow for easier payment by other
payers.
| A9283 | Foot pressure off-loading/supportive device, any type, each. |
| L3925 | Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), non-torsion joint/spring, extension/flexion, may include soft interface material, prefabricated, includes fitting and adjustment. |
| L3927 | Finger orthosis, proximal interphalangeal (PIP)/distal interphalangeal (DIP), without joint/spring, extension/flexion (e.g., static or ring type), may include soft interface material, prefabricated, includes fitting and adjustment. |
| L3929 | Hand finger orthosis, includes one or more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. |
| L3931 | Wrist hand finger orthosis, includes one or more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, prefabricated, includes fitting and adjustment. |
| L7611 |
Terminal device, hook, mechanical, voluntary opening, any material, any size, lined or unlined, pediatric. |
| L7612 | Terminal device, hook, mechanical, voluntary closing, any material, any size, lined or unlined, pediatric. |
| L7613 | Terminal device, hand, mechanical, voluntary opening, any material, any size, pediatric. |
| L7614 | Terminal device, hand, mechanical, voluntary closing, any material, any size, pediatric. |
| L7621 | Terminal device, hook or hand, heavy duty, mechanical, voluntary opening, any material, any size, lined or unlined. |
| L7622 | Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined. |
Deleted codes
Most of the deleted codes are for wrist/hand/finger
orthoses, which are being replaced by new codes. However, one torso
support code has been removed, along with four knee orthosis
codes. See the section on “The Financial Impact of
Crosswalking” for crosswalk information and some statistics on
what specialties are currently providing most of the care for these
deleted codes.
| L0960 | Torso support, post-surgical support, pads for post-surgical support. |
| L1855 | Knee orthosis, molded plastic, thigh and calf sections, with double upright, knee joints, custom-fabricated. |
| L1858 |
Knee orthosis, molded plastic, polycentric knee joints, pneumatic knee pads (CTI), custom-fabricated. |
| L1870 | Knee orthosis, double upright, thigh and calf lacers with knee joints, custom-fabricated. |
| L1880 | Knee orthosis, double upright, non-molded thigh and calf cuffs/lacers with knee joints, custom-fabricated. |
| L3800 | Wrist hand finger orthosis, short opponens, no attachments, custom-fabricated. |
| L3805 | Wrist hand finger orthosis, long opponens, no attachments, custom-fabricated. |
| L3810 | WHFO, addition to short and long opponens, thumb abduction (“C”) bar. |
| L3815 |
WHFO, addition to short and long opponens, second M.P. abduction assist. |
| L3820 | WHFO, addition to short and long opponens, I.P. extension assist, with M.P. extension stop. |
| L3825 | WHFO, addition to short and long opponens, M.P. extension stop. |
| L3830 |
WHFO, addition to short and long opponens, M.P. extension assist. |
| L3835 | WHFO, addition to short and long opponens, M.P. spring extension assist. |
| L3840 | WHFO, addition to short and long opponens, spring swivel thumb. |
| L3845 | WHFO, addition to short and long opponens, thumb I.P. extension assist, with M.P. stop. |
| L3850 | WHO, addition to short and long opponens, action wrist, with dorsiflexion assist. |
| L3855 | WHFO, addition to short and long opponens, adjustable M.P. flexion control. |
| L3860 | WHFO, addition to short and long opponens, adjustable M.P. flexion control and I.P. |
| L3907 | Wrist hand finger orthosis, wrist gauntlet with thumb spica, custom-fabricated. |
| L3910 | Wrist hand finger orthosis, Swanson design, prefabricated, includes fitting and adjustment. |
| L3916 | Wrist hand finger orthosis, wrist extension cock-up with outrigger, prefabricated, includes fitting and adjustment. |
| L3918 | Hand finger orthosis, knuckle bender, prefabricated, includes fitting and adjustment. |
| L3920 |
Hand finger orthosis, knuckle bender with outrigger, prefabricated, includes fitting and adjustment. |
| L3922 | Hand finger orthosis, knuckle bender, two segment to flex joints, prefabricated, includes fitting and adjustment. |
| L3924 | Wrist hand finger orthosis, Oppenheimer, prefabricated, includes fitting and adjustment. |
| L3926 | Wrist hand finger orthosis, Thomas suspension, prefabricated, includes fitting and adjustment. |
| L3928 | Hand finger orthosis, finger extension, with clock spring, prefabricated, includes fitting and adjustment. |
| L3930 | Wrist hand finger orthosis, finger extension, with wrist support, prefabricated, includes fitting and adjustment. |
| L3932 |
Finger orthosis, safety pin, spring wire, prefabricated, includes fitting and adjustment. |
| L3934 | Finger orthosis, safety pin, modified, prefabricated, includes fitting and adjustment. |
| L3936 |
Wrist hand finger orthosis, Palmer, prefabricated, includes fitting and adjustment. |
| L3938 | Wrist hand finger orthosis, dorsal wrist, prefabricated, includes fitting and adjustment. |
| L3940 | Wrist hand finger orthosis, dorsal wrist, with outrigger attachment, prefabricated, includes fitting and adjustment |
| L3942 | Hand finger orthosis, reverse knuckle bender, prefabricated, includes fitting and adjustment. |
| L3944 | Hand finger orthosis, reverse knuckle bender, with outrigger, prefabricated, includes fitting and adjustment |
| L3946 | Hand finger orthosis, composite elastic, prefabricated, includes fitting and adjustment. |
| L3948 | Finger orthosis, finger knuckle bender, prefabricated, includes fitting and adjustment. |
| L3950 | Wrist hand finger orthosis, combination Oppenheimer, with knuckle bender and two attachments, prefabricated, includes fitting and adjustment. |
| L3952 | Wrist hand finger orthosis, combination Oppenheimer, with reverse knuckle and two attachments, prefabricated, includes fitting and adjustment. |
| L3954 |
Hand finger orthosis, spreading hand, prefabricated, includes fitting and adjustment. |
| L3985 | Upper extremity fracture orthosis, forearm, hand with wrist hinge, custom-fabricated. |
| L3986 | Upper extremity fracture orthosis, combination of humeral, radius/ulnar, wrist (example: Colles’ fracture), custom-fabricated. |
| 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 similar to the new code, CMS will often assign the new code the same allowable amount as the already existing, related 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. Medicare determines an allowable for a new code in this situation through a process called gap-filling. This method requires each Medicare carrier 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 recalculated 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 its basis 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. 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 “In the News” and AOPA In Advance. |
Changes in code descriptors
The majority of code changes affect the E codes used for progressive
stretch devices, which are rental items. CMS also continued its process
of removing manufacturer brand names from several battery codes. (New
wording has been bolded in the following chart.)
| Code | Old Descriptor | New Descriptor |
| E1801 | Bi-directional static progressive stretch elbow device with range-of-motion adjustment, includes cuffs. | Static progressive stretch elbow device, extension and/or flexion, with or without range-of-motion adjustment, includes all components and accessories. |
| E1806 | Bi-directional static progressive stretch wrist device with range-of-motion adjustment, includes cuffs. | Static progressive stretch wrist device, flexion and/or extension, with or without range-of-motion adjustment, includes all components and accessories. |
| E1811 | Bi-directional static progressive stretch knee device with range-of-motion adjustment, includes cuffs. | Static progressive stretch knee device, flexion and/or extension, with or without range-of-motion adjustment, includes all components and accessories. |
| E1816 | Bi-directional static progressive stretch ankle device with range-of-motion adjustment, includes cuffs. | Static progressive stretch ankle device, flexion and/or extension, with or without range-of-motion adjustment, includes all components and accessories. |
| E1841 | Multidirectional static progressive stretch shoulder device, with range-of-motion adjustability, includes cuffs. | Static progressive stretch shoulder device, with or without range-of-motion adjustment, includes all components and accessories. |
| L3806 | Wrist hand finger orthosis, includes one or more non-torsion joint(s), elastic bands, turnbuckles, may include soft interface material, straps, custom-fabricated, includes fitting and adjustment. | Wrist hand finger orthosis, includes one or more non-torsion joint(s), turnbuckles, elastic bands/springs, may include soft interface material, straps, custom-fabricated, includes fitting and adjustment. |
| L7360 | Six-volt battery, Otto Bock or equal, each. | Six-volt battery, each. |
| L7362 | Battery charger, six-volt, Otto Bock or equal. | Battery charger, six-volt, each. |
| L7364 | Twelve-volt battery, Utah or equal, each. | Twelve-volt battery, each. |
| L7366 | Battery charger, twelve-volt, Utah or equal. | Battery charger, twelve-volt, each. |
The Financial Impact of Crosswalking
Medicare is continuing to delete specific codes and
replace them with a smaller number of global codes. Though these
replacement, or “crosswalk” codes, do provide
reimbursement, the change can still have a financial impact on O&P.
Below is a chart of the codes deleted by CMS for
2008, along with what code has replaced the deleted code. In some
instances, CMS has not provided a replacement code. When appropriate,
the chart also shows the 2007 floor and ceiling fee schedule amounts for the
deleted code and the “crosswalked” code. For 2008 fee schedule information on these codes, go to www.AOPAnet.org and click on "Coding and Billing Reimbursement." The final column shows the top
three specialties paid for the code in 2005 (the most recent data
available at press time). This chart should help you determine the
financial impact of this year’s code deletions on your business,
based upon the volume of each specific code you use.
| Deleted Code | Fee Schedule Range | CMS Crosswalk Code | Fee Schedule Range | Number Paid & Top Three Specialties Paid in 2005 |
| L0960 | $54.23 to $72.31 | None | None | No services paid in 2005 |
| L1855 | $862.76 to $1,150.34 | L1846 | $833.56 to $1,111.42 | 1,622 paid 30% paid to medical supply company with O&P 27% paid to medical supply company 13% paid to certified prosthetist |
| L1858 | $940.78 to $1,254.38 | L1846 | $833.56 to $1,111.42 | 3,155 paid 41% paid to medical supply company 17% paid to certified orthotist 12% paid to certified prosthetist |
| L1870 | $821.64 to $1,095.52 | L1846 | $833.56 to $1,111.42 | 173 paid 70% paid to certified orthotist 11% paid to medical supply company with O&P 6% paid to certified prosthetist |
| L1880 | $555.71 to $740.95 | L1846 | $833.56 to $1,111.42 | 628 paid 44% paid to medical supply company 21% paid to certified orthotist 12% paid to orthopedic surgeon |
| L3800 | $153.63 to $204.84 | L3808 | $192.66 to $256.89 | 20,517 paid 34% paid to orthopedic surgeon 15% paid to OT 10% paid to medical supply company |
| L3805 | $245.81 to $327.74 | L3808 | $192.66 to $256.89 | 12,395 paid 21% paid to orthopedic surgeon 15% paid to OT 11% paid to medical supply company with orthotist |
| L3810 | $49.79 to $66.39 | None | None | 5,186 paid 25% paid to medical supply company 16% paid to orthopedic surgeon 15% paid to certified orthotist |
| L3815 | $46.22 to $61.63 | None | None | 616 paid 80% paid to medical supply company 5% paid to orthopedic surgeon 3% paid to hand surgeon |
| L3820 | $79.39 to $105.86 | None | None | 1,313 paid 56% paid to medical supply company with orthotist 12% paid to certified orthotist 7% paid to orthopedic surgeon |
| L3825 | $49.82 to $66.43 | None | None | 441 paid 31% paid to medical supply company with O&P 18% paid to orthopedic surgeon 10% paid to OT |
| L3830 | $65.04 to $86.72 | None | None | 757 paid 25% paid to medical supply company with orthotist 20% paid to OT 17% paid to PT |
| L3835 | $70.51 to $94.02 | None | None | 179 paid 65% paid to orthopedic surgeon 8% paid to OT 7% paid to PT |
| L3840 | $48.29 to $64.39 | None | None | 1,163 paid 63% paid to medical supply company with orthotist 10% paid to certified orthotist 8% paid to orthopedic surgeon |
| L3845 | $62.37 to $83.15 | None | None | 1,811 paid 40% paid to medical supply company with orthotist 16% paid to orthopedic surgeon 11% paid to certified orthotist |
| L3850 | $89.09 to $118.79 | None | None | 247 paid 21% paid to certified orthotist 19% paid to medical supply company 12% paid to unspecified physician specialty |
| L3855 | $89.81 to $119.74 | None | None | 506 paid 48% paid to medical supply company 17% paid to certified orthotist 8% paid to OT |
| L3860 | $122.92 to $163.90 | None | None | 675 paid 34% paid to OT 20% paid to medical supply company 12% paid to PT |
| L3907 | $390.27 to $520.36 | L3808 | $192.66 to $256.89 | 6,478 paid 34% paid to orthopedic surgeon 15% paid to OT 5% paid to pharmacy |
| L3910 | $288.18 to $384.24 | L3931 | Allowable not yet set | 1,374 paid 75% paid to medical supply company 8% paid to orthopedic surgeon 4% paid to certified orthotist |
| L3916 | $97.58 to $130.10 | L3931 | Allowable not yet set | 3,490 paid 32% paid to medical supply company 17% paid to orthopedic surgeon 6% paid to medical supply company with orthotist |
| L3918 | $60.21 to $80.28 | L3929 | Allowable not yet set | 511 paid 25% paid to orthopedic surgeon 23% paid to OT 7% paid to PT |
| L3920 | $75.24 to $100.32 | L3929 | Allowable not yet set | 72 paid 38% paid to orthopedic surgeon 26% paid to OT 8% paid to certified orthotist |
| L3922 | $75.13 to $100.17 | L3929 | Allowable not yet set | 146 paid 41% paid to OT 14% paid to orthopedic surgeon 10% paid to pharmacy |
| L3924 | $81.92 to $109.23 | L3931 | Allowable not yet set | 1,061 paid 28% paid to medical supply company 25% paid to orthopedic surgeon 12% paid to medical supply company with orthotist |
| L3926 | $71.33 to $95.10 | L3931 | Allowable not yet set | 85 paid 29% paid to medical supply company 19% paid to pharmacy 18% paid to medical supply company with O&P |
| L3928 | $44.72 to $59.62 | L3929 | Allowable not yet set | 1,934 paid 39% paid to orthopedic surgeon 15% paid to OT 10% paid to certified orthotist |
| L3930 | $47.27 to $63.02 | L3929 | Allowable not yet set | 8,668 paid 48% paid to medical supply company 28% paid to orthopedic surgeon 5% paid to pharmacy |
| L3932 | $36.11 to $48.14 | L3925 | Allowable not yet set | 1,154 paid 32% paid to orthopedic surgeon 23% paid to OT 10% paid to medical supply company |
| L3934 | $37.02 to $49.36 | L3929 | Allowable not yet set | 6,868 paid 53% paid to medical supply company with orthotist 13% paid to orthopedic surgeon 11% paid to OT |
| L3936 | $68.44 to $91.25 | L3931 | Allowable not yet set | 2,429 paid 35% paid to orthopedic surgeon 13% paid to medical supply company 11% paid to OT |
| L3938 | $71.66 to $95.55 | L3931 | Allowable not yet set | 3,371 paid 28% paid to orthopedic surgeon 23% paid to medical supply company 14% paid to pharmacy |
| L3940 | $82.59 to $110.12 | L3931 | Allowable not yet set | 376 paid 36% paid to orthopedic surgeon 25% paid to medical supply company 9% paid to medical supply company with pharmacy |
| L3942 | $57.12 to $76.16 | L3929 | Allowable not yet set | 1,285 paid 23% paid to OT 21% paid to orthopedic surgeon 8% paid to certified orthotist |
| L3944 | $75.46 to $100.61 | L3929 | Allowable not yet set | 86 paid 47% paid to OT 12% paid to orthopedic surgeon 10% paid to certified orthotist |
| L3946 | $68.09 to $90.78 | L3929 | Allowable not yet set | 2,935 paid 34% paid to orthopedic surgeon 28% paid to OT 7% paid to clinic |
| L3948 | $43.24 to $56.45 | L3925 | Allowable not yet set | 1,695 paid 58% paid to orthopedic surgeon 16% paid to OT 4% paid to PT |
| L3950 | $115.21 to $153.62 | L3931 | Allowable not yet set | 385 paid 85% paid to medical supply company 3% paid to medical supply company with O&P 3% paid to orthopedic surgeon |
| L3952 | $127.87 to $170.49 | L3931 | Allowable not yet set | 82 paid 57% paid to medical supply company 9% paid to OT 9% paid to medical supply company with orthotist |
| L3954 | $84.85 to $113.13 | L3923 | $26.56 to $35.42 | 5,235 paid 65% paid to medical supply company 11% paid to medical supply company with O&P 6% paid to certified prosthetist/orthotist |
| L3985 | $449.04 to $598.72 | L3764 | $926.92 to $1,235.89 | 342 paid 23% paid to OT 19% paid to group practice 19% paid to certified orthotist |
| L3986 | $430.63 to $574.17 | L3763 | $875.34 to $1,167.12 | 1,455 paid 39% paid to orthopedic surgeon 15% paid to OT 8% paid to PT |
Kathy Dodson is the senior director of government affairs for the
American Orthotic & Prosthetic Association (AOPA). Questions? Call
(571) 431-0810 or visit www.AOPAnet.org.
