HCPCS Code L0642

Official Description

Lumbar orthosis, sagittal control, with rigid anterior and posterior panels, posterior extends from l-1 to below l-5 vertebra, produces intracavitary pressure to reduce load on the intervertebral discs, includes straps, closures, may include padding, shoulder straps, pendulous abdomen design, prefabricated, off-the-shelf

Short Descr	Lo sag ri an/pos pnl pre ots
Coverage	Carrier Priced
Pricing Indicator(s)	38 – Supplies And Surgical Dressings - Orthotics, prosthetics, prosthetic devices & vision services (price subject to floors and ceilings)
MPI	A – Not applicable, as HCPCS priced under one methodology
BETOS	D1F – Prosthetic/Orthotic devices
TOS Code(s)	P – Lump sum purchase of DME, prosthetics, orthotics
Added Date	1/1/2014
APC Status Indicator	Service Paid under Fee Schedule or Payment System other than OPPS
MUE	0
MUE	1
OTS Orthotic	No

KV	Dmepos item subject to dmepos competitive bidding program that is furnished as part of a professional service
KX	Requirements specified in the medical policy have been met
CG	Policy criteria applied
GA	Waiver of liability statement issued as required by payer policy, individual case
KT	Beneficiary resides in a competitive bidding area and travels outside that competitive bidding area and receives a competitive bid item
J5	Off-the-shelf orthotic subject to dmepos competitive bidding program that is furnished as part of a physical therapist or occupational therapist professional service
GZ	Item or service expected to be denied as not reasonable and necessary
GX	Notice of liability issued, voluntary under payer policy
RA	Replacement of a dme, orthotic or prosthetic item
50	Bilateral procedure: unless otherwise identified in the listings, bilateral procedures that are performed at the same session, should be identified by adding modifier 50 to the appropriate 5 digit code. note: this modifier should not be appended to designated "add-on" codes (see appendix d).
95	Synchronous telemedicine service rendered via a real-time interactive audio and video telecommunications system: synchronous telemedicine service is defined as a real-time interaction between a physician or other qualified health care professional and a patient who is located at a distant site from the physician or other qualified health care professional. the totality of the communication of information exchanged between the physician or other qualified health care professional and the patient during the course of the synchronous telemedicine service must be of an amount and nature that would be sufficient to meet the key components and/or requirements of the same service when rendered via a face-to-face interaction. modifier 95 may only be appended to the services listed in appendix p. appendix p is the list of cpt codes for services that are typically performed face-to-face, but may be rendered via a real-time (synchronous) interactive audio and video telecommunications system.
CC	Procedure code change (use 'cc' when the procedure code submitted was changed either for administrative reasons or because an incorrect code was filed)
CK	At least 40 percent but less than 60 percent impaired, limited or restricted
CQ	Outpatient physical therapy services furnished in whole or in part by a physical therapist assistant
CR	Catastrophe/disaster related
GG	Performance and payment of a screening mammogram and diagnostic mammogram on the same patient, same day
GP	Services delivered under an outpatient physical therapy plan of care
GV	Attending physician not employed or paid under arrangement by the patient's hospice provider
GW	Service not related to the hospice patient's terminal condition
GY	Item or service statutorily excluded, does not meet the definition of any medicare benefit or, for non-medicare insurers, is not a contract benefit
KY	Dmepos item subject to dmepos competitive bidding program number 5
KZ	New coverage not implemented by managed care
LT	Left side (used to identify procedures performed on the left side of the body)
NU	New equipment
PO	Excepted service provided at an off-campus, outpatient, provider-based department of a hospital
Q6	Service furnished under a fee-for-time compensation arrangement by a substitute physician or by a substitute physical therapist furnishing outpatient physical therapy services in a health professional shortage area, a medically underserved area, or a rural area
RT	Right side (used to identify procedures performed on the right side of the body)
ST	Related to trauma or injury