New Bracing Code Takes Effect Oct. 1st

What You Need to Know

• Code Number: L1681
• Code Description: HIP ORTHOSIS, BILATERAL HIP JOINTS AND THIGH CUFFS, ADJUSTABLE FLEXION, EXTENSION, ABDUCTION CONTROL OF HIP JOINT, POSTOPERATIVE HIP ABDUCTION TYPE, PREFABRICATED ITEM THAT HAS BEEN TRIMMED, BENT, MOLDED, ASSEMBLED, OR OTHERWISE CUSTOMIZED TO FIT A SPECIFIC PATIENT BY AN INDIVIDUAL WITH EXPERTISE

The joint publication from the DME MACs and PDAC notes that this code describes "a prefabricated orthosis with a semirigid, or rigid waist band connected to bilateral rigid uprights that includes a hip joint and a rigid thigh cuff. Both hip joints provide adjustable for extension/flexion as well as abduction; the hip joint aligns and maintains the femur in an abducted position." The brace is customarily applied in the post-operative setting.

 The effective date for this code is October 1st of this year. While state-specific fee schedule information is not yet available at the time of writing, the HCPCS Coding Workgroup has stated that the average 2023 fee schedule amount "would be approximately $2,249.62."

There are also several prefabricated HCPCS codes that only describe custom fit orthoses and do not have an OTS equivalent code. If you provide an orthosis that does not have an OTS code but only "minimal self-adjustment" was performed at delivery, you must bill using the appropriate miscellaneous code (L2999, L3999, or L4999). These custom fit code descriptions typically end with "PREFABRICATED, INCLUDES FITTING AND ADJUSTMENT." A list of custom fit only codes can be found here, and further instructions on billing miscellaneous codes for OTS devices can be found here. 

What This Means for You

First, make sure that your billing software is updated to include L1681 before October 1st. Medicare created this code to alleviate confusion about the appropriate use of already-existing code L1690. Going forward, you'll want to verify whether L1690 or L1681 is the more appropriate code to use depending on the specific type of brace you're delivering/the modifications you are performing to it. 

Second, as the code language indicates, this is a custom-fit code. Supporting clinical documentation must therefore include a description of the modifications made to the brace at the time of delivery by a qualified person. Those modifications must be more than minimal self-adjustment that patients can perform on their own. 

We will continue to monitor future developments connected to L1681. If the DME MACs publish any coverage-specific guidance about this code in the future, we will let you know.