Lower Limb Prostheses LCD

What You Need to Know:

In this installment we are going to focus on the “Foot” and “Knee” sections of the Lower Limb Prostheses LCD.

Prosthetic Feet

1. Prosthetic feet described by either L5970 or L5974 are covered for individuals whose functional level (i.e., K-level) is 1 or higher.
2. Prosthetic feet described by either L5972 or L5978 are covered for individuals whose functional level is 2 or higher.
3. Prosthetic feet described by L5973, L5976, L5979, L5980, L5981, and L5987 are covered for individuals whose functional level is 3 or higher.
4. L5969 – the code describing a microprocessor-controlled ankle or foot system with power assist – is not covered for Medicare beneficiaries. Similarly, user-adjustable heel height (L5990) is not reasonable and necessary for Medicare beneficiaries.

Prosthetic Knees

1. L5930 (high activity knee control frame) is covered for individuals whose functional level is 4.
2. Prosthetic knees described by L5610, L5613, L5614, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856, L5857, and L5858 are covered for individuals whose functional level is 3 or above.
3. L5859 (powered and programmable flexion/extension assist control) requires all of the following elements: (a) the patient has a microprocessor controlled knee (L5856); (b) the patient’s functional level is 3; (c) the patient has a documented comorbidity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K3 level function with a passive microprocessor knee; (d) the patient can use a product that requires daily charging; and (e) the patient can understand and respond to error alerts and alarms from the unit.
4. All other knee systems – L5611, L5616, L5710, L5711, L5712, L5714, L5716, L5718, L5810, L5811, L5812, L5816, L5818 – are covered for patients whose functional level is 1 or higher.
   

What This Means for You:

First, as you can see from the preceding lists, the foot and knee L-codes are explicitly linked to certain functional (K) levels. It is important, therefore, for you to make sure that your documentation and the corroborating documentation of a physician demonstrate that the patient’s K level corresponds with the coded item.

Second, pay attention to which codes are either non-covered altogether by Medicare or have specific requirements as a precondition to payment.

Third, ideally your EMR should be flagging all of the above issues for you to avoid coding problems. If it isn’t, you should explore whether there is software functionality that you are not utilizing that would protect you from running afoul of these requirements.

Next in this series: Ankles, Hips, and Sockets.