2025 HCPCS code L0642
(Active) Effective Date: N/A Revision Date: N/A Orthotic Procedures and Services - Lumbar Orthotics Sagittal Control Orthotics Feed
Supply of a prefabricated, off-the-shelf lumbar orthosis with sagittal control.
Modifiers may apply depending on the circumstances of service. Consult the appropriate modifier guidelines for additional information.
Medical necessity is established by documentation of a diagnosis that warrants the use of a lumbar orthosis, such as chronic lower back pain, spinal instability, or post-surgical recovery.The physician should document the patient's symptoms, the expected benefits of the orthosis, and why a less costly treatment would not suffice.
The clinical responsibility involves assessing the patient's need for lumbar support, determining the appropriate type of orthosis (in this case, L0642), fitting the patient with the device, and instructing them on proper use and care.Follow-up adjustments may also be necessary.
In simple words: This code covers the cost of a special back brace (lumbar orthosis) that helps support your lower back and limits how much it bends.It's a ready-made brace, not custom-fit.
This HCPCS code represents the supply of a prefabricated lumbar orthosis designed to provide sagittal plane movement restriction.The orthosis features rigid anterior and posterior panels, extending posteriorly from the L1 to below the L5 vertebra. Its design incorporates intracavitary pressure to reduce stress on intervertebral discs.Included are straps and closures; padding and shoulder straps may also be present. A pendulous abdomen design with additional support straps may be incorporated.Fitting and adjustment are included and should not be billed separately.
Example 1: A patient presents with chronic lower back pain due to degenerative disc disease.The physician orders a prefabricated lumbar orthosis (L0642) for support and pain reduction., A patient recovering from a lumbar spine fracture requires a rigid orthosis to provide stability and limit movement during the healing process. The L0642 brace is deemed appropriate., A patient with spondylolisthesis experiences significant lower back pain and instability.A physician orders a lumbar orthosis (L0642) to provide support and reduce pain.
Physician's order specifying the need for a lumbar orthosis,patient's medical history and diagnosis,documentation of the fitting and adjustment of the orthosis, and patient education on proper use and care.
** This code includes fitting and adjustment of the orthosis.Separate billing for these services is not allowed.Always ensure that the specific design and features of the supplied orthosis match the code description.
- Payment Status: Active
- Modifier TC rule: A Technical Component (TC) modifier is not typically applicable to this code, as it represents the supply of an item.
- Fee Schedule : Fee schedules vary based on payer and location.Consult payer-specific fee schedules for current rates.Historical data is not consistently available across all payers.
- Specialties:Orthopedics, Physical Medicine and Rehabilitation, Neurosurgery
- Place of Service:Office, Outpatient Hospital, Ambulatory Surgical Center