Not Otherwise Classified (NOC) Codes Explained

What You Need to Know:

There are a total of 8 NOC codes for orthotic and prosthetic devices/services:

• L0999: Addition to spinal orthosis
• L1499: Spinal orthosis
• L2999: Lower extremity orthoses
• L3649: Orthopedic shoe modifications
• L3999: Upper limb orthosis
• L5999: Lower extremity prosthesis
• L7499: Upper extremity prosthesis
• L8499: Miscellaneous prosthetic services

You should use an NOC code when no other specific L-code adequately describes the item provided. This means that the NOC code should not overlap with features or functions included in existing L-codes. For example, the value of the time spent fitting, delivering, and training a patient to use an orthotic or prosthetic device is already included in the L code describing that device. Therefore, the MACs and PDAC would view the use of an NOC code to separately bill for a clinician's time engaging in those activities as overlapping with a feature or function in the specific code describing the brace or prosthesis. They would therefore classify that activity as inappropriate unbundling.

When submitting a claim with a NOC code, you must include specific information about the product: (1) a description of the item/service; (2) the manufacturer's name; (3) the product name and number; (4) the supplier price list amount; and (5) the HCPCS code of a related item (if applicable). If you do not include this information, the DME MAC will reject your claim and require you to resubmit.

Upon receiving a claim that includes an NOC code, Medicare and other payers must then determine the amount to pay for the item, as NOC codes do not have a set fee schedule amount. This means that they have to individually review these claims. Medicare will look at a variety of factors - for example, fee schedule amounts for comparable items, supplier price lists, and manufacturer's wholesale price - in an effort to arrive at a reasonable payment amount. Commercial payers, on the other hand, typically have a defined formula for NOC codes that is part of your provider agreement with them.

What This Means for You:

First, understanding when and how to correctly use NOC codes will protect your business from avoidable audits and inquiries initiated by Medicare contractors. Using an NOC code when an existing code already describes the function or feature is exactly the kind of activity that review entities will seize on as indicative of abuse or fraud. In other words, be thoughtful about when you're using NOC codes.

Second, it is important to understand that using NOC codes is an accepted billing practice. NOC codes were created for a reason - to allow appropriate coding of and reimbursement for items that are not described by other L codes. Indeed, there are products on the market today that have received PDAC coding verification for an NOC code. While you need to make sure that you only use NOC codes in instances where including them is appropriate, you should use them in those situations.

Third, even though NOC codes do not have a set fee schedule amount, you should be able to determine the likely payment for a particular item, especially if you are using an NOC code in a claim submitted to a commercial health plan. There, you need simply look at your provider agreement, which spells out how the insurer calculates payment for NOC codes.

NOC codes are widely misunderstood and often avoided by providers. However, it is important to understand that they are a part of the HCPCS coding system for a reason. Some bracing and prosthetic solutions - especially groundbreaking new ones - fall outside the descriptions of existing L codes. By following the rules around correct NOC code use, you can minimize your claim risk and offer innovative, new solutions to your patients.