Joint DME MAC and PDAC Publication
The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have noticed a substantial increase in claim submissions for HCPCS code L1686 (HIP ORTHOSIS, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT). 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.
L1686 describes a prefabricated orthosis with a semirigid or rigid waist band connected to a single rigid upright, hip joint and rigid thigh cuff. The hip joint is adjustable for extension/flexion as well as abduction; the hip joint aligns and maintains the femur in an abducted position. This orthosis is typically used in the post-operative setting. L1686 is a complete product, as it is inherent in the definition of “prefabricated” that a particular item is complete. Custom-fabricated additions will be denied as incorrect coding if billed with the L1686 prefabricated orthosis, since custom fabricated additions are only appropriate for custom-fabricated base orthotics.
L1686 includes fitting and adjustment at the time of delivery. Devices that are prefabricated and include fitting and adjustment are also referred to as 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 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.
For questions about correct coding, contact the Pricing, Data Analysis and Coding (PDAC) Contact Center at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday, or e-mail the PDAC.
||Published on PDAC website