Billing Repairs

What You Need to Know

Medicare will pay for repairs of a covered orthosis or prosthesis due to wear or accidental damage starting 90 days after delivery. The repair must be required to make the device functional and cannot exceed the cost of replacement or be covered under warranty. While a new order is not required, there must be documentation from the treating physician that the item continues to be reasonable and necessary. This requirement can be satisfied with a medical records entry showing usage of the item within the last 12 months or a recent order/prescription for the repair itself. The supplier's documentation must also justify the repair, including a description of the issue, components replaced, labor time, and nature of the repair.

Providers can use the following HCPCS codes to bill for an orthotic or prosthetic repair:

Repair/Replace Minor Parts

• L4210: Repair of orthotic device, repair or replace minor parts
• L7510: Repair of prosthetic device, repair or replace minor parts

* Claim narrative must include the HCPCS code of the base item being repaired, a description of each item that is billed, and the Supplier Price List (PL) amount

Labor

• L4205: Repair of orthotic device, labor component, per 15 minutes
• L7520: Repair prosthetic device, labor component, per 15 minutes

* Claim narrative must include an explanation of what is being repaired

For any parts with a specific HCPCS code that are replaced as part of the repair, providers should not use the repair codes listed above. Instead, they should bill the established HCPCS code that describes the replaced component and include the RB modifier on the claim line. In this scenario, providers cannot bill HCPCS codes L7520 or L4205 because labor is already included in the allowance for established HCPCS codes.

What This Means for You

If you are not currently billing for repairs, you are likely missing out on additional reimbursement from Medicare and other payers for the services you already provide. When a patient returns to your office for an adjustment or repair to their device more than 90 days after delivery, those modifications might be reimbursable by the patient's insurance if the above criteria are met. Understanding the correct billing procedures, documentation standards, and HCPCS coding for repairs is essential to ensure compliance and receive timely reimbursement.

HCPCS codes L7510 (prosthetics) and L4210 (orthotics) are used to bill for minor materials and/or components used to complete the repair. These codes do not have a set reimbursement, and payment is dependent on the manufacturer's or supplier's invoice. If you send a component back to the manufacturer for repair outside of the warranty period, you can use this code to get reimbursed for the manufacturer's repair costs.

In addition to billing for the repair components, you can also bill for any time you spend on the repair yourself by using HCPCS code L7520 (prosthetics) or L4205 (orthotics). Unlike the component codes, the labor codes have a set Medicare fee schedule. One unit represents 15 minutes of labor, so you should bill the proper quantity to accurately reflect your time (e.g., quantity of 4 equates to 1 hour). The total time reported should reflect time spent on the repair itself, and should not include other professional services, such as patient evaluation, casting, fitting, gait training, programming, etc.

It is also important to be aware that Medicare has the following MUE limits for these codes:

• L4210: 4
• L7510: 4
• L4205: 8 (2 hours)
• L7520: 12 (3 hours)

If you bill for a quantity greater than these limits on a single date of service, you will receive an automatic denial. However, you can appeal the denial, and the DME MACs may pay for the extra units if there is adequate documentation of medical necessity.

For more information, review Noridian's article on Repairs.