Lower Limb Prostheses LCD

This is the final installment of a 6-part series walking through Medicare’s Lower Limb Prostheses Local Coverage Determination. In today’s post we’ll cover the Policy Article that accompanies this LCD.

What You Need to Know:

Many people fail to realize that the Local Coverage Determination is not the only document they have to review to fully understand Medicare’s coverage and claim requirements. The LCD has an accompanying Policy Article addressing a variety of topics that we’ll walk through below. The Policy Article lists “Non-Medical Necessity Coverage and Payment Rules” – also referenced as “statutory payment policy requirements” – in addition to the LCD:

1. What Payment Includes. The Policy Article defines what is included in payment for a lower limb prosthesis: (a) residual limb and gait evaluations; (b) prosthetic fitting; (c) cost of base components and labor; (d) repairs due to normal wear and tear within 90 days of delivery; and (e) adjustments to the prosthesis/component(s) at the time of fitting and for 90-days post-delivery if the adjustments are not the result of changes to the patient’s residual limb or functional abilities.
2. Hospitals and SNF’s. The Policy Article reminds you that a prosthesis delivered in an in-patient hospital stay and used by the patient for inpatient treatment or rehabilitation should not be separately billed to Medicare, as it is part of the global payment made to the hospital. It provides a summary overview of the 48-Hour Rule, a narrow exception to the prohibition on billing hospitals for items dispensed during a hospital stay. And it identifies the group of codes for which billing a Skilled Nursing Facility is inappropriate, as well as the situations in which billing Medicare for a prosthesis dispensed in a SNF is valid.
3. Adjustments, Repairs, and Replacements. The Policy Article generally describes when adjustments, repairs, and replacements are and are not covered. Most notably, this section includes the 3 situations in which replacement of a prosthesis or component is covered: (a) when the beneficiary’s physiological condition changes; (b) when the device/part of it has irreparable wear; or (c) the cost of repairing the prosthesis/part would be more than 60% of the cost of a replacement prosthesis/part.
4. Code-Specific Guidance. A significant portion of the Policy Article is devoted to specific L codes – K-level requirements for certain codes, documentation requirements for certain codes, code combinations that cannot be billed together, and certain codes for which there is no Medicare coverage.

What This Means for You:

The Policy Article for Lower Limb Prostheses is not just extra information. With the LCD, it completes the comprehensive description of coverage and payment rules that apply to lower limb prostheses. It is critical that you review, understand, and comply with the Policy Article’s requirements just as you must comply with those of the LCD. Indeed, there are numerous code-specific requirements in the Policy Article that you must be familiar with and comply with to avoid non-payment of claims or post-payment audit recoupments.

We hope you have found this 6-part series on the Lower Limb Prostheses LCD and Policy Article useful. We will update you in the future if either of these documents is revised by Medicare.