2025 HCPCS code L0624
(Active) Effective Date: N/A Revision Date: N/A Deletion Date: N/A Orthotic Procedures and services - Sacral Orthotics Orthotic Procedures and services L0112-L4631 > Sacral Orthotics L0621-L0624 Feed
Supply of a custom-fabricated sacroiliac orthosis with a rigid or semi-rigid panel over the sacrum and abdomen, providing pelvic and sacral support.
Modifiers may be applicable depending on the circumstances of service; consult local guidelines and payer requirements.
Medical necessity is established by documentation supporting the diagnosis of sacroiliac joint dysfunction or instability, the conservative treatment options attempted and their failure, and the expectation that the custom-fabricated sacroiliac orthosis will provide significant improvement in pain, stability, and function.
A physician (e.g., orthopedist, physiatrist) or other qualified healthcare professional assesses the patient's condition, determines the need for a sacroiliac orthosis, and orders the custom fabrication.The orthotists fabricate and fit the orthosis.
- Orthotic Procedures and services L0112-L4631 > Sacral Orthotics L0621-L0624
- L0621-L0624 (Sacral Orthotics)
In simple words: This code covers the cost of a custom-made brace for support of the lower back and pelvis.The brace is made to fit the patient perfectly and helps stabilize the joints in that area, relieving pain.
This HCPCS code represents the supply of a custom-fabricated sacroiliac orthosis.This orthosis is designed to immobilize the sacroiliac joints and provide support to the pelvis and sacrum.The brace is manufactured specifically for the individual patient based on their size, shape, and needs.It features a rigid or semi-rigid panel over the sacrum and abdomen, offering additional support to the joints.The orthosis may include a pendulous abdomen design with an extra strap for added support in patients with weakened abdominal muscles.
Example 1: A patient presents with chronic sacroiliac joint pain and instability.After a thorough evaluation, the physician orders a custom-fabricated sacroiliac orthosis (L0624) to provide support and pain relief., A post-surgical patient requires additional support to stabilize their sacroiliac joint during recovery. A custom-fabricated sacroiliac orthosis (L0624) is prescribed to assist in healing and prevent further injury., A patient with significant muscle weakness in their abdominal wall experiences pelvic instability and pain.A custom sacroiliac orthosis (L0624) with a pendulous abdomen design is prescribed to provide additional support and reduce pain.
Physician's order specifying a custom-fabricated sacroiliac orthosis, patient's medical history and physical examination findings documenting the need for the orthosis, details of the orthosis (materials, design, measurements), and confirmation of the fitting and delivery of the orthosis.
** The specific design and features of the sacroiliac orthosis will influence the overall cost.Detailed documentation is crucial for appropriate reimbursement.
- Payment Status: Active
- Modifier TC rule: Not applicable.This code represents the supply of the orthosis itself.
- Specialties:Orthopedics, Physical Medicine and Rehabilitation
- Place of Service:Office, Outpatient Hospital, Other Place of Service (depending on where the orthosis is supplied)