Post Pay Audits on Replacement Sockets

DME MAC Jurisdiction C announced they will begin a widespread post-pay review on HCPCS Codes L5700 (Replacement, Socket, Below Knee, Molded to Patient Model) and L5701 (Replacement, Socket, Above Knee/Knee Disarticulation, Including Attachment Plate, Molded to Patient Model).

What Does This Mean for You?

If you have submitted a claim Region C with codes L5700 or L5701, you are subject to possible audits. This means you will receive an Additional Documentation Request (ADR) letter from CGS. It is important to respond with the information requested. The following documents will need to be provided along with the response:

• SWO/DWO
• Physician’s medical notes
• Prosthetist’s records
• Documentation which details the reason for a replacement socket and identifies continued use of the prosthesis.

A replacement socket may be medically necessary under the following conditions:

• Significant changes in the patient's condition.
• Changes in the residual limb.
• Functional need changes
• The device is beyond repair.
• Repairs exceed 60 % of the cost of the replacement.
• The prosthesis is lost or stolen.

This is not an all inclusive list as each case is unique. The reason for socket replacement needs to be detailed in the prosthetist’s notes and corroborated in the physician’s notes.

You may read the original announcement here.