Coding

Terminology
"Orthosis Versus Splint"
The Definition of L codes
Choosing the Correct L code
Other L codes Relating to Orthotics
CPT Codes Associated with Orthotics
Comparison Chart: L code vs. CPT Codes for Orthotics
Addition Codes
Bilateral Orthoses
L3923
Silver Ring Splints
History of L codes


Terminology

Orthotics — The science of fabricating and fitting orthoses.

Orthosis — Used to describe a single device. A rigid or semi-rigid device that supports a weak or deformed body member, or restricts or eliminates motion in a diseased or injured part of the body. An orthosis can be custom fabricated, custom fit or prefabricated.

Orthoses — Used to describe multiple devices.

Prefabricated — Off-The-shelf: Orthoses that requires minimal self adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling or customizing to fit the beneficiary.

Custom Fitted — A-prefabricated device, which is manufactured in quantity without a specific patient in mind. The device may or may not be supplied as a kit that requires some assembly and/or fitting and adjustment, or a device that must be trimmed, bent, molded (with or without heat) or otherwise modified by an individual with expertise in customizing the item to be fit and used by a specific patient.

Custom Fabricated — A custom-fabricated item is one that is individually made for a specific patient. No other patient would be able to use this item. A custom fabricated item is a device that is fabricated based on clinically derived and rectified castings, tracings, measurements and/or other images (such as X-rays) of the body part. The fabrication may involve using calculations, templates and components. This process requires the use of basic materials including, but not limited to plastic, metal, leather or cloth in the form of uncut or unshaped sheets, bars or other basic forms and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling and finishing prior to fitting on the patient.

Splint — The term splint refers to casts and strapping for reductions of fractures and dislocations. The term splinting should not be used by therapists fabricating or issuing an orthosis.  This term is often used by physician's offices or therapists for applying a cast. TheCPT codes for splinting can be found here.

Without Joints — When this phrase is in the code description the orthosis is static and does not have a dynamic or static progressive component.. Elastic bands and Turnbuckles —These terms in the code description indicate at least one joint (but could be multiple joints) has a dynamic or static progressive component(s) acting upon it. The intent is to mobilize an anatomical area.

Elastic Bands and Turnbuckles — If these terms are in the description then this indicates at least one joint, but could be multiple joints, has a dynamic or static progressive component(s) acting upon it. The intent is to mobilize an anatomical area.

Top of Page


"Orthosis" Versus "Splint"

Orthosis is the proper term that applies to a custom-fabricated brace/splint. Medicare considers an orthosis a rigid or semi-rigid device that supports a weak or deformed body member, or restricts or eliminates motion in a diseased or injured part of the body. Orthoses can be custom fabricated, custom fit or prefabricated. Medicare covered orthoses must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member.

Congress passed a provision of the Social Security Act that states no payment shall be made for certain custom fabricated orthoses unless such items are furnished by a "qualified practitioner." The definition of "qualified practitioner" includes "qualified occupational therapists" and "qualified physical therapists" as well as other professions. Orthoses require a prescription and/or certificate of medical necessity signed by a physician. Orthoses can be provided to the patient in their home, and in other settings such as outpatient centers and SNFs.

CMS defines orthoses and sets the fee schedule for the L codes. See below for the definitions of the different type of orthoses described by CMS.

Prefabricated/Off-the-Shelf: Orthoses that require minimal self adjustment for appropriate use and do not require expertise in trimming, bending, molding, assembling or customizing to fit the beneficiary.

Custom Fitted: A prefabricated device, which is manufactured in quantity without a specific patient in mind. The device may or may not be supplied as a kit that requires some assembly and/or fitting and adjustment, or a device that must be trimmed, bent, molded (with or without heat) or otherwise modified by an individual with expertise in customizing the item to fit and be used by a specific patient.

Custom Fabricated: A custom-fabricated item is one that is individually made for a specific patient. No other patient would be able to use this item. A custom-fabricated item is a device that is fabricated based on clinically derived and rectified castings, tracings, measurements and/or other images of the body part (such as X-rays). The fabrication may involve using calculations, templates and components. This process requires the use of basic materials including, but not limited to plastic, metal, leather or cloth in the form of uncut or unshaped sheets, bars or other basic forms and involves substantial work such as vacuum forming, cutting, bending, molding, sewing, drilling and finishing prior to fitting on the patient.

Splint: Refers to casts and strapping used for reductions of fractures and dislocations.

Note: The term "splinting" should not be used by therapists who are fabricating or issuing orthoses. The term is used by physician offices for applying a cast. There are CPT codes for splinting that are used when billing for this service.

Orthosis is the singular noun for a custom-molded or pre-fabricated support.

Orthoses is the plural noun for two or more custom-molded or pre-fabricated supports.

Orthotic is the adjective. Instead of saying splint fabrication, the correct term is orthotic fabrication.

As DME scrutiny increases, being consistent with terminology use will help avoid reimbursement denials.

Top of Page


The Definition of L codes

An L code is a level II healthcare common procedural coding system (HCPCS) code. An HCPCS code is a five-character alphanumeric code. The first character is a letter that describes the type of service billed and the other four numeric characters describe the specific type of service. L codes are codes that bill for orthotics and prosthetics provided to patients. The “L” identifies the code is for an orthotic or prosthetic, and the numbers define what body part and type of orthosis/prosthesis, e.g. L 3906 is a custom fabricated static wrist hand orthosis.

View a complete listing of the L-codes currently used by CMS.

Top of Page


Choosing the Correct L Code

The complete description and codes for Medicare covered supplies and equipment are listed in the Medicare alpha-numeric Level II HCPCS file. Codes for orthoses or L Codes can be found in the “L” section beginning on line 4096 on the Excel spreadsheet. The code is listed, followed by a long and a short description of the orthosis. These codes are also available on the ASHT website. The L code should be submitted with the appropriate modifier signifying right or left (RT or LT).

The description following the code indicates the joints covered or influenced by the orthosis (S=Shoulder, E=Elbow, W=Wrist, H=Hand, and F=Finger) followed by the letter O for Orthosis. They are also described as without joints (static) or with nontorsion joints, elastic bands or turnbuckles (dynamic) and as prefabricated (P/F), off the shelf (OTS) or custom fabricated (C/F). See below for more detail on the differences between these categories.

The Medicare fee schedule for each code varies by state. After opening the file, find the Excel spreadsheet. The L codes begin on line 1862. States are listed across the top of the page so you will have to find your location and scroll down. The fee schedule is updated quarterly, so we recommend checking it each quarter. 

These codes include the charge for orthosis assessment time (or evaluation), fabrication time and materials. It also includes teaching the patient to apply and remove the orthosis, cleaning and care and precautions for wearing it. The L-code price includes minor adjustments on subsequent visits.

Off-the-Shelf Orthotics (OTS)
New regulations have been adopted for coding prefabricated or “ off-the-shelf” orthotics. These have been divided into two categories each with a different code. The first describes prefabricated orthoses “requiring minimal self-adjustment for use and don’t require expertise for trimming, bending, molding assembling or customizing the fit to the individual.” These are orthoses that can be adjusted by the patient, a caretaker or a supplier who does not have specialized training in orthotics or prosthetics. The second is for prefabricated orthoses that do “require expertise in customizing the orthotic to fit the individual patient.”

For example, L3809 is a prefabricated static WHFO that requires minimal adjustment and L3807 is the same, but requires molding, trimming etc in order to correctly fit and align the patient. The documentation in the chart must indicate the changes made to justify the expert adjustment choice.

The following codes are those OTS codes most likely to be used by hand therapists:

Prefabricated, minimal adjustment prefabricated, expert adjustment required.

Prefabricated, minimal adjustment Prefabricated, expert adjustment required
L3809 L3807
L3916 L3915
L3918 L3917
L3924 L3923
L3930 L3929
L 3761 L3760

(For a list of current codes for OTS, please visit the CMS website.)

Computer Aided Design and Manufactured Orthoses

Use of CAD (computer aided design)/CAM (computer aided manufactured) or similar technology to create an orthosis without a positive model of the patient may be considered as OTS if the final fitting upon delivery to the patient requires minimal self-adjustment. More information is available here.

Again, we recommend photographing the orthosis before and after, and keeping this in the patient’s medical file.

Top of Page


Other L Codes Relating to Orthotics

There are three additional L Codes that can be used to bill for revisions to orthotics. There is no clear reimbursement fee schedule for all the codes and the therapist should check with the patient’s insurance provider before using these codes.

  • L 4205 Repair of orthotic device, labor component, per 15 minutes
  • L 4210 Repair of orthotic device, repair or replace minor parts
  • L 4002 Replacement strap, any orthotic, includes all components, any length, any type

Top of Page


CPT Codes Associated with Orthotics

  • 97760 Orthotic(s) management and training (including assessment and fitting when not otherwise reported), upper extremity(s), lower extremity(s) and/or trunk, each 15 minutes. This code may be used to bill for training the patient to use the orthosis. The HCPCS L code includes evaluation, fabrication and fitting. The code does not include training that may be necessary for the orthosis to be effective. This code may also be used at a later date if the patient requires additional training. For example, training that may be necessary for a tenodesis orthosis to be effective. Documentation must support the use of both codes.
  • 97761 Prosthetic training, upper and/or lower extremity(s), each 15 minutes.
  • 97762 Checkout for orthotic/prosthetic use, established patient, each 15 minutes. May be used to bill for re-evaluation or assessment of the effectiveness, fit or patient’s use of an orthosis during a follow-up visit. Because this is an established patient, it cannot be used with an evaluation or re-evaluation code, except 97760. If used with 97760, a modifier is required. Documentation must adequately support the repeated use of this code, including justification for this service exceeding 8 minutes. An example would be if a patient returns following orthosis fabrication and 97762 is billed to assess fit, range of motion, etc. and this check reveals the orthosis requires significant adjustment due to improved range of motion or substantial volume changes. It would be appropriate to bill 97760 for the modifications to the orthosis along with 97762, the check that revealed the need for modification.

Top of Page


Comparison Chart: L code vs. CPT Codes for Orthotics

The chart below provides a quick overview of the different requirements, use of and billing for using L codes compared to CPT codes. More detailed information is available under the specific coding headings in this section.

Please click here to view the chart.

Top of Page


Addition Codes

The addition codes were deleted by CMS in 2008 after the new L codes were implemented.

Top of Page


Bilateral Orthoses

If bilateral orthoses are prescribed, use the “Rt” modifier to bill for the right orthosis and the “Lt” modifier to bill for the left one.

Top of Page


L3923

Effective July 1, 2010: CMS placed restrictions on reimbursement for braces comprised entirely of elastic. If an HFO or garment is made entirely of elastic, spandex, neoprene or similar material, it is not considered a “brace” and cannot be billed to Medicare using the L3923 code. Private payers may not require the modifier and should be consulted directly.

Medicare does recognize elastic supports that have additional plastic or metal inserts. If the HFO orthosis or support meets this requirement and is custom adjusted, it can be submitted with code L3923 and the CG modifier. The CG modifier indicates that “policy criteria has been applied” meaning the support includes or is comprised of plastic and/or metal and that it requires the skill of a professional for molding or fitting. Supports made entirely of elastic must be billed with code A4466, which is not payable by Medicare.

For more information, please click here.

Top of Page


Silver Ring Splints

According to the advice of a CMS MAC representative, a therapist can bill the L 3933 code for silver ring splints. The therapist measures the patient for the orthosis, and the silver ring splint company manufactures the orthosis. The therapist pays for the finished silver ring splint and provides the orthosis to the patient. The therapist can bill for the orthosis because it is still custom fabricated for the patient; however, the therapist must have a DMEPOS provider number if they are billing Medicare part B, and they would bill the MAC for their region. Because there are four different MACs for the 50 states, it would be best to check with the MAC for your region if they will reimburse the L 3933 code for the silver ring splints.

Top of Page


History of L Codes

In 2006, CMS collaborated with the ASHT L Code Task Force to create a new set of L codes that accurately described the orthotics that hand therapists make as part of their therapeutic interventions. In 2006/2007, 24 new codes were implemented, which are listed below. In addition to these 24 codes, there are two L codes (3906 and 3730) that were in existence prior to the ASHT/CMS collaboration. Both codes apply to custom-molded orthotics and were already in use by therapists as well as orthotists. Because the codes accurately described orthotics that therapists already fabricate, they were left as is. CMS recently revised some L codes as of January 1, 2011. These are further explained below.

The pictorial examples given for each code are provided only for instructional purposes and are not to be construed as the only type of orthosis that can be fabricated using that orthotic code. As long as your custom orthosis can be described by the specific code, as outlined below, then that is the code you will utilize to bill for your orthosis.

Medicare covered orthoses must be reasonable and necessary for the diagnosis or treatment of an illness or injury or to improve the functioning of a malformed body member. Congress passed a provision of the Social Security Act that states no payment shall be made for certain custom-fabricated orthoses unless such items are furnished by a “qualified practitioner” who further includes a “qualified occupational therapist” and “qualified physical therapist” as well as other professions. Orthoses require a prescription and/or certificate of medical necessity signed by a physician. Orthoses can be provided to the patient in their home, and in other settings such as outpatient centers and SNFs. CMS defines orthoses (found in the HCPCS Level II manual) and sets the fee schedule for the L codes.

Top of Page