Coding Issues

Correct Coding Guidance for L6700 (Upper Extremity Prosthetic Myoelectronic Control)

The DME MACs and the PDAC have released a “Correct Coding” bulletin for L6700 (upper extremity addition, external powered feature, myoelectric control module, additional EMG inputs, pattern-recognition decoding intent movement).  The L6700 became effective April 1, 2025, and the predicate products for the L6700 are tare Coapt’s Complete Control Gen2, Ottobock’s MyoPlus, and Infinite Biomedical Technologies’ Sense.

The bulletin states that the L6700 describes an addition to an upper extremity prosthesis and has the following components/features:

  1. The capacity to gather, decode, and integrate simultaneous myographic signals from a minimum array of 3 electromyographic (EMG) sites.
  2. The product’s machine learning algorithms recognize and simultaneously decode complex EMG patterns in determining an individual’s real-time movement intent. The product translates command signals into commands to direct functional motion of electric powered components.
  3. The product provides intuitive control of myoelectric prosthetic components, such as terminal devices, wrist units, elbows, etc.

The bulletin also introduced a code verification requirement for the L6700. Beginning on July 1, 2025, the only items which may be billed using L6700 are those reviewed by the PDAC and published on the PDAC Product Classification List.

New HCPCS Codes & Code Changes Effective April 1, 2025

There are 13 new L-codes and six new A-codes, which will be active and valid for claims with dates of service on or after April 1, 2025:

  • L0720-Cervical-thoracic-lumbar-sacral-orthoses (ctlso), anterior-posterior-lateral control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1933-Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated, off-the-shelf
  • L1952-Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, off-the-shelf
  • L5827-Endoskeletal knee-shin system, single axis, electromechanical swing and stance phase control, with or without shock absorption and stance extension damping
  • L6028-Partial hand including fingers, flexible or non-flexible interface, endoskeletal system, molded to patient model, for use without external power, not including inserts described by L6692
  • L6029-Upper extremity addition, test socket/interface, partial hand including fingers
  • L6030-Upper extremity addition, external frame, partial hand including fingers
  • L6031-Replacement socket/interface, partial hand including fingers, molded to patient model, for use with or without external power
  • L6032-Addition to upper extremity prosthesis, partial hand including fingers, ultralight material (titanium, carbon fiber or equal
  • L6033-Addition to upper extremity prosthesis, partial hand including fingers, acrylic material
  • L6037-Immediate post-surgical or early fitting, application of initial rigid dressing, including fitting alignment and suspension of components, and one cast change, partial hand including fingers
  • L6700-Upper extremity addition, external powered feature, myoelectronic control module, additional emg inputs, pattern-recognition. decoding intent movement
  • L7406-Addition to upper extremity, user adjustable, mechanical, residual limb volume management system
  • A6515-Gradient compression wrap with adjustable straps, full leg, each, custom
  • A6516-Gradient compression wrap with adjustable straps, foot, each, custom
  • A6517-Gradient compression wrap with adjustable straps, below knee, each, custom
  • A6518-Gradient compression wrap with adjustable straps, arm, each, custom
  • A6519-Gradient compression garment, not otherwise specified, for nighttime use, each
  • A6611-Gradient compression wrap with adjustable straps, above knee, each, custom

Five L-codes and six A-codes, had their descriptors updated and will be active and valid for claims with dates of service on or after April 1, 2025.

  • L1951-Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise.
  • L1932 -Ankle foot orthosis, rigid anterior tibial section, total carbon fiber or equal material, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1971- Ankle foot orthosis, plastic or other material with ankle joint, with or without dorsiflexion assist, prefabricated, includes fitting and adjustment
  • L6692 -Upper extremity addition, silicone gel insert or equal, with or without locking mechanism, each
  • L6698- Addition to upper extremity prosthesis, lock mechanism, excludes socket insert
  • A6549 -Gradient compression garment, not otherwise specified, for daytime use, each
  • A6583-Gradient compression wrap with adjustable straps, below knee, each
  • A6585 -Gradient compression wrap with adjustable straps, above knee, each
  • A6586 -Gradient compression wrap with adjustable straps, full leg, each
  • A6587-Gradient compression wrap with adjustable straps, foot, each” to describe foot gradient compression wraps.
  • A6588- Gradient compression wrap with adjustable straps, arm, each

The code L8010 (Breast prosthesis, mastectomy sleeve) is being deleted, a will no longer be active for claims with dates of service on or after April 1, 2025. In its place you may use codes A6576, A6577, or A6578.

Coding Verification Requirement for L1843 and L1951

The DME MACs and the PDAC have just released an announcement that following codes will require PDAC coding verification for all claims with a date of service on or after December 1, 2024:

  • L1843 – Knee orthosis, single upright, thigh and calf, with adjustable flexion and extension joint (unicentric or polycentric), medial-lateral and rotation control, with or without varus/valgus adjustment, prefabricated item that has been trimmed bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1951 – Ankle foot orthosis, spiral, (institute of rehabilitative medicine type), plastic or other material, prefabricated, includes fitting and adjustment

So, beginning on December 1, 2024 the only items which may be billed using codes L1843 and L1951 are those published on the PDAC Product Classification List. Any items currently listed as L1843 or L1951 on the PDAC Product Classification List will not need to be reverified. Also, please be reminded that the codes L1843 and L1951 are subject to prior authorization starting August 12, 2024.

New HCPCS Codes Effective October 1, 2024

The three new HCPCS codes are :

  • L1006- Scoliosis orthosis, sagittal-coronal control provided by a rigid lateral frame, extends from axilla to trochanter, includes all accessory pads, straps and interface, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1653- Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size, prefabricated, off the shelf
  • L1821- Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated, off the shelf

Two codes have verbiage changes (changes in bold):

  • L1652-Hip orthosis, bilateral thigh cuffs with adjustable abductor spreader bar, adult size,prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise
  • L1820- Knee orthosis, elastic with condylar pads and joints, with or without patellar control, prefabricated item that has been trimmed, bent, molded, assembled, or otherwise customized to fit a specific patient by an individual with expertise

The new codes and code changes will be active and valid for claims with dates of service on or after October 1, 2024.

DME MACs/PDAC Releases 3D Printing Guidance

The Durable Medicare Equipment Medicare Administrative Contractors (DME MACs) and the Pricing Data Analysis & Coding (PDAC) contractor released long awaited guidance from the Centers for Medicare and Medicaid Services (CMS) on the use of 3D printing and digital scanning for custom fabricated orthoses. They state that 3D printing, or additive manufacturing, can be an acceptable alternative to traditional custom fabrication, if the method used meets the definition of custom fabricated in the DMEPOS Quality Standards, Appendix C. This new correct coding reminder is consistent with AOPA’s position that 3D printing/additive manufacturing should be considered a valid custom fabrication method. This is another positive step in CMS, DME MACs and PDAC accepting the newer orthotic technologies. View the full guidance.  

Correct Coding of Custom Fitted Orthotic HCPCS Codes Without a Corresponding OTS Code

The DME MACs and the PDAC published a joint correct coding bulletin regarding code descriptors that include the term “prefabricated, includes fitting and adjustment”. Some of the orthotic HCPCS codes that simply state, “prefabricated, includes fitting and adjustment”, or do not have a corresponding off-the-shelf code, are to be classified as custom fitted orthoses, and therefore may only be used to describe orthoses that require customization and/or modification by a certified orthotist or other properly trained individual.  Orthoses described by these type of codes that are delivered as OTS, without customization and/or modification must be billed using the appropriate not otherwise specified code (L1499, L2999, L3999).  View the correct coding bulletin.

Items Requiring Coding Review by the PDAC

Manufacturers and patient care facilities are reminded that a number of items require coding review by the Pricing, Data Analysis and Coding (PDAC) contractor; and a PDAC coding review is binding when billing Medicare. Here is a list of items which require a PDAC coding review and the PDAC’s Product Classification List.

 

For more CMS coding updates and reminders please review the PDAC Advisory Articles.