Article - Spinal Orthoses: TLSO and LSO - Policy Article (A52500)

Items that are prefabricated.They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to custom fitted.OTS items require minimal self-adjustment for fitting at the time of delivery for appropriate use and do not require expertise in trimming, bending, and molding, assembling, or customizing to fit an individual.This fitting does not require expertise of a certified orthotist or an individual who has specialized training in the provision of orthoses to fit the item to the individual beneficiary.The term minimal self-adjustment is defined at 42 CFR 414.402 as an adjustment the beneficiary, caretaker for the beneficiary, or supplier of the device can perform and that does not require the services of a certified orthotist (that is, an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification) or an individual who has specialized training. For example, adjustment of straps and closures, bending or trimming for final fit or comfort (not all-inclusive) fall into this category. See more than minimal self-adjustment definition below for additional information.Custom fitted orthotics are:Devices that are prefabricated.They may or may not be supplied as a kit that requires some assembly. Assembly of the item and/or installation of add-on components and/or the use of some basic materials in preparation of the item does not change classification from OTS to 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 at delivery does require expertise of a certified orthotist or an individual who has specialized training in the provision of the orthosis to fit the item to the individual beneficiary.In contrast to minimal self-adjustment, more than minimal self-adjustment is defined as changes made to achieve an individualized fit during the final fitting at the time of delivery of the item that requires the expertise of a certified orthotist or an individual who has specialized training in the provision of orthotics in compliance with all applicable Federal and State licensure and regulatory requirements. A certified orthotist is defined as an individual who is certified by the American Board for Certification in Orthotics and Prosthetics, Inc., or by the Board for Orthotist/Prosthetist Certification.Correct coding of prefabricated orthoses is dictated by actions that take place at the time of fitting to the beneficiary, either custom-fitted (requiring expertise) or OTS (requiring minimal self-adjustment).Corresponding HCPCS Code SetsFor many prefabricated orthoses, corresponding sets of HCPCS codes are available which describe the identical types of items. The corresponding code sets, when available for identical products, are only differentiated by the nature of the final fitting performed at the time of delivery. The corresponding HCPCS code types are:HCPCS codes which describe PREFABRICATED, OFF-THE-SHELF. These HCPCS codes must be used when minimal self-adjustment is the extent of the fitting performed at delivery.HCPCS codes which describe PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE. These HCPCS codes must be used when more than minimal self-adjustment is necessary and performed at delivery.In the following table, the HCPCS codes located in Column I and Column II within the same row are considered a corresponding HCPCS code set. These codes represent identical products which are only differentiated by the nature of the final fitting performed at the time of delivery.Column IColumn IIL0454L0455L0456L0457L0466L0467L0468L0469L0626L0641L0627L0642L0630L0643L0631L0648L0633L0649L0637L0650L0639L0651For some prefabricated orthoses, corresponding sets of HCPCS codes (which describe the identical types of items) are not available. HCPCS codes with long descriptions of PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT describe custom fitted items. For these HCPCS codes there are no corresponding OTS codes. When the unique HCPCS code that most closely describes the product includes PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT in the HCPCS long description, the supplier must:Code the product using the unique HCPCS code, if the product was custom fitted at the time of delivery to the beneficiary; or,Code the product using a miscellaneous HCPCS code, if the product was not custom fitted at delivery to the beneficiary and, instead, was provided as OTS to the beneficiary. The miscellaneous HCPCS code for billing of spinal orthoses is HCPCS code L1499.SPINAL ORTHOSESSpinal orthoses (L0450, L0452, L0454, L0455, L0456, L0457, L0458, L0460, L0462, L0464, L0466, L0467, L0468, L0469, L0470, L0472, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0621, L0622, L0623, L0624, L0625, L0626, L0627, L0628, L0629, L0630, L0631, L0632, L0633, L0634, L0635, L0636, L0637, L0638, L0639, L0640, L0641, L0642, L0643, L0648, L0649, L0650, L0651) have the following characteristics:Used to immobilize the specified areas of the spineIntimate fit and generally designed to be worn under clothingNot specifically designed for beneficiaries in wheelchairsIn addition to (1) and (2), the body jacket type orthoses (L0458, L0460, L0462, L0464, L0480, L0482, L0484, L0486, L0488, L0490, L0491, L0492, L0639, L0640, L0651) are characterized by a rigid plastic shell that encircles the trunk with overlapping edges and stabilizing closures and provides a high degree of immobility. The entire circumference of the plastic shell must be the same rigid material.A rigid or semi rigid orthotic device eliminates or restricts motion in the planes being controlled by an orthosis.A spinal orthosis is designed to control gross movement of the trunk and intersegmental motion of the vertebrae in one or more planes of motion:Lateral/flexion (side bending) in the coronal/frontal plane. Control of this plane is achieved by a rigid panel in the mid-axillary line, which is either an integral part of a posterior or anterior panel, or a separate panel.Anterior flexion (forward bending) or posterior extension (backward bending) in the sagittal plane. Control of this plane is achieved by a rigid posterior panelAxial rotation (twisting) viewed in the transverse plane. Straps over the shoulders attaching to a posterior panel alone do not provide transverse spinal control.The purpose of a rigid or semi-rigid LSO and TLSO spinal orthosis is to restrict the effect of the forces within a three-point pressure system. The posterior panel must encompass the paraspinal muscle bodies from one lateral border to another in order to provide sufficient surface area to enhance the three-point pressure system. The posterior panel must provide coverage to meet the minimum height requirements as described in the individual HCPCS codes. Spinal Orthoses that do not meet the Medicare definition of a brace should be coded as A9270.For an item to be classified as a TLSO the posterior portion of the brace must extend from the sacrococcygeal junction to just inferior to the scapular spine. This excludes elastic or equal shoulder straps or other strapping methods. The anterior portion of the orthosis must at a minimum extend from the symphysis pubis to the xiphoid. Some TLSOs may require the anterior portion of the orthosis to extend up to the sternal notch.Maternity support garments, which are products that are designed to provide support for the abdomen during pregnancy, do not meet the definition of a brace. These products are coded using A9270 (NON-COVERED ITEM OR SERVICE). L-codes for orthoses must not be used for these items.ELASTIC AND SIMILAR STRETCHABLE MATERIALSFor items where the HCPCS code specifies elastic or other similar terminology for stretchable material, use the code that is most applicable to the item. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code.For items where the HCPCS code does not specify elastic or other similar terminology for stretchable material, the following guidelines apply:Items that are primarily constructed of elastic or other stretchable materials (e.g. support items made of material such as neoprene or spandex (elastane, Lycra) (not all-inclusive)) must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).Items that are primarily constructed of elastic or other stretchable materials (e.g. support items made of material such as neoprene or spandex (elastane, Lycra]) (not all-inclusive)) that contain stays and/or panels must be coded as A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).Items that are primarily of constructed inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) that are incapable of providing the necessary immobilization or support to the body part for which it is designed and that have stays and/or panels capable of providing the required immobilization or support to the body part for which it is designed, must be coded using A4467 (BELT, STRAP, SLEEVE, GARMENT, OR COVERING, ANYTYPE).Items that are primarily constructed of inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) capable of providing the necessary immobilization or support to the body part for which it is designed must be coded using the applicable specific HCPCS code for the type of product. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and any relevant coding guideline for the criteria applicable for each HCPCS code.Items that are primarily of constructed inelastic material (e.g., canvas, cotton or nylon (not all-inclusive)) capable of providing the necessary immobilization or support to the body part for which it is designed and that have stays and/or panels capable of providing the required immobilization or support to the body part for which it is designed, must be coded using the applicable specific HCPCS code for the type of product. A NOC (Not Otherwise Classified) or miscellaneous HCPCS code must not be used instead of the specific code. Refer to the long code narrative and relevant coding guideline for the criteria applicable for each HCPCS code.Items that are not capable of providing the necessary immobilization or support to the body part for which it is designed (regardless of materials) must be coded using A9270 (NONCOVERED ITEM OR SERVICE).Codes L0450, L0454, L0455, L0621, L0625, and L0628 may only be used for orthoses that are made primarily of nonelastic material (e.g., canvas, cotton or nylon).