Lower Limb Prostheses LCD

What You Need to Know:

The third part of the LCD is the “General” section, which provides guidance in 6 areas:

1. If the DME MACs determine that a prosthesis is not reasonable and necessary, any related additions will also be denied on the same basis.
2. The following L codes will be denied as not reasonable and necessary when billed in conjunction with an initial or preparatory below-knee prosthesis: L5629, L5638, L5639, L5646, L5670, L5647, L5704, L5785, L5962, and L5980.
3. The following L codes will be denied as not reasonable and necessary when billed in conjunction with a below-knee preparatory prefabricated prosthesis: L5620, L5629, l5645, L5646, L5670, L5676, L5704, and L5962.
4. The following L codes will be denied as not reasonable and necessary when billed in conjunction with an initial or preparatory above-knee prosthesis: L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, L5710, L5711, L5712, L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5790, and L5795.
5. The following L codes will be denied as not reasonable and necessary when billed in conjunction with an above-knee preparatory prefabricated prosthesis: L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964, and L5966.
6. Finally, the LCD states that in the next section – addressing specific coverage criteria for prosthetic feet, knees, ankles, etc., all of which will be covered in the next two articles in this series – references to how specific components map to the functional levels (K-levels) represent the “usual case.” The LCD then provides that “[e]xceptions will be considered in an individual case if additional documentation is included which justifies medical necessity.”

What This Means for You:

First, it is important for you to make sure that, ideally, your EMR prevents you from billing the codes listed in 2-5 above when used in conjunction with the base codes describing initial and preparatory BK/AK prostheses, as well as the base codes describing preparatory prefabricated BK/AK prostheses. If your EMR cannot prevent the use of those codes together, it should, at a minimum, flag that these codes should not be billed simultaneously.

Second, recognize that while the LCD’s maps specific foot, knee, ankle, and hip L codes to specific K levels, you have the right to argue that a component described by one of those codes should be considered for a patient not described by the associated K level. The reason for this is that the LCD’s guidance about those components represents the “usual case,” but the LCD explicitly permits you to seek an exception. If you do so, you should document in detail why, for example, a K3 foot would be the best option for a specific K2 patient.

Next in this series: Feet and Knees.