PDAC Required Verification for 6 L-Codes

The Issue

As we have written about previously, CMS plans on expanding its prior authorization program to many prosthetic L-codes. Today, the DME MACs announced that as part of that process, products using any of the 6 L-codes listed below must be PDAC-verified to obtain Medicare reimbursement for those devices beginning on January 1st, 2021:

1. L5973 - ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE
2. L5980 - ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM
3. L5987 - ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON
4. L5856 - ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
5. L5857 - ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
6. L5858 - ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE

What does this mean for you?

Beginning on January 1st of next year, if you bill Medicare for any device using one of these codes and that device has not gotten PDAC verification, Medicare will deny payment for that item. To avoid this happening, you must therefore make sure that beginning this January, you only use products described by these codes that have received coding verification from the PDAC. You can visit the PDAC's DMECS site here to see products already verified for these codes.

We will keep you updated if and when new information about PDAC verification of codes and/or Medicare prior authorization becomes available.