LLP Pre Authorization and PDAC Verification of Ӧssur Products

The Issue 

As part of CMS’s Lower Limb Prostheses Prior Authorization program, all products associated with the following codes – the first 3 of which describe microprocessor-controlled knees, and the last 3 of which describe certain K3 feet – must be verified by PDAC: 

• L5856 
• L5857 
• L5858 
• L5973 
• L5980 
• L5987 

For products to be eligible for prior authorization, manufacturers must submit any products they believe are described by these codes before January 1, 2021. (www.dmepdac.com) 

Newly-Verified Products 

Ӧssur and other manufacturers have submitted relevant products to PDAC for coding verification. To date, the following products not previously verified by PDAC have been added to PDACs verified products webpage: 

What Does This Mean For You? 

There are three key takeaways from the coding verifications published so far. First, the initial results for the already-reviewed prosthetic feet suggest that the coding guidance for L5980, L5981 and L5987 published earlier this year by the DME MACs in the Policy Article for Lower Limb prostheses is reshaping the base codes applicable to prosthetic feet. Specifically, it appears that many feet historically coded as L5980 and L5987 will be reclassified into the L5981 code. Second, based on the initial verifications, we believe that many feet historically coded with L5984 and/or L5986 will lose these add-on codes when verified by PDAC, as it looks like PDAC is taking a narrower view of what L5984 and L5986 describe. Third, PDAC’s review process is ongoing. You should be checking the PDAC’s website daily to confirm whether any new products have been added to the verification list. Once there, we recommend the following: 

1. Click on the “Product Classification List” button. 
2. Enter the applicable HCPCS code. 
3. When the results table appears, click on the “Effective Begin Date” heading so that results get organized from newest to oldest. 
4. Repeat for each of the other 5 HCPCS codes subject to prior authorization.  

We will continue to keep you apprised of results over the next several months from time to time.  

For more information or assistance with your reimbursement questions, please contact us at [email protected].