Lower Limb Prostheses LCD

What You Need to Know:

In this installment we are going to focus on the “Ankles,” “Hips,” and “Sockets” sections of the Lower Limb Prostheses LCD.

Prosthetic Ankles

• Axial rotation units (L5982, L5984, L5985, and L5986) are covered for individuals whose functional level is 2 or higher.

Hips

• A pneumatic or hydraulic polycentric hip joint (L5961) is covered for individuals whose functional level is 3 or higher.

Sockets

• More than two diagnostic (“test”) sockets are not reasonable and necessary for a single prosthesis unless the medical record contains documentation justifying the need.
• Diagnostic/test sockets are not reasonable and necessary for post-operative prostheses described by codes L5400-L5460.
• A maximum of two of the same socket inserts (liners) are allowed per individual prosthesis at the same time. The codes describing those items are: L5654, L5655, L5656, L5658, L5661, L5665, L5673, L5679, L5681, L5683.
• In order to replace a socket, you must provide adequate documentation of functional and/or physiological need.

What This Means for You:

First, the above-listed ankle codes and the hip joint code 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, some people misinterpret the guidance on diagnostic (test) sockets to mean that you can automatically bill for two of them for every patient. That is not accurate. The LCD is defining two specific instances where diagnostic sockets are not reasonable and necessary (i.e., uncovered): (1) when delivering more than two of them for a single prosthesis (unless you can specifically document the reason why more were needed); and (2) if the patient is receiving a post-operative prosthesis. These limitations do not relieve you of the obligation to justify the need for a second diagnostic socket if you use more than one. In other words, the LCD is implicitly stating that up to two diagnostic sockets can be reasonable and necessary, but you should be detailing why more than one is needed if you do fabricate a second one.

Third, the LCD explicitly limits liners to a maximum of two per patient per limb.

Finally, you must provide specific clinical documentation outlining the reasons why a replacement socket is medically necessary.

Next in this series: the final article will cover the Policy Article accompanying the LCD.