ET, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website. This fitting method at delivery must require expertise of a certified orthotist or an individual who has specialized training in the provision of an orthosis to fit the item to the individual beneficiary.įor questions about correct coding, contact the PDAC Contact Center at 87 during the hours of 9:30 a.m. 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. Devices that are prefabricated and include fitting and adjustment are also referred to as custom fitted. L1005 includes fitting and adjustment at the time of delivery. As discussed in previous posts, PDAC verification is required for 6 HCPCS codes (L5973, L5980, L5987 feet and L5856, L5857, L5858 knee codes) for the Medicare LLP Prior Authorization Program. Custom-fabricated additions will be denied as incorrect coding if billed with the L1005 prefabricated orthosis, since custom fabricated additions are only appropriate for custom-fabricated base orthotics. L1005 is a complete product, as it is inherent in the definition of "prefabricated" that a particular item is complete. This orthosis is designed to control or support against further progression of an adolescent idiopathic scoliosis curve. The multiple components create tension forces to exert a dynamic force on the torso for resisting the scoliosis curve. All products submitted to PDAC for a coding verification review are carefully examined by coders and professionals following a formal, standardized process. ![]() ![]() The spinal orthosis contains multiple tension features (Tension bands, straps, or pads – not all inclusive) which connect to a semi rigid pelvic structure. The PDAC provides coding decisions based on the coding guidelines established by the Local Coverage Determination (LCD) and associated policy article developed by the DME MACs. The DME MACs and the Pricing, Data Analysis and Coding (PDAC) Contractor are providing this article to educate suppliers to correctly code products which are described by this L-code.Ĭode L1005 describes a spinal orthosis used to treat scoliosis. The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have noticed a substantial increase in claim submissions for HCPCS code L1005 (TENSION BASED SCOLIOSIS ORTHOSIS AND ACCESSORY PADS, INCLUDES FITTING AND ADJUSTMENT).
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