Skip navigation
9

David McGill Blogger

Back to Basics: The Prosthetic LCD (Part 3)

Posted by David McGill | August 16, 2013

​Congratulations. You've now reached the heart of the Lower Limb Prostheses LCD. There's a lot to cover here but we'll try to keep it as brief and simple as possible.

General

Under the entirely unhelpful heading of "General," which many people believe is a euphemism​ for "Not All That Important" - don't make that mistake! - the LCD lays out key requirements for below-knee and above-knee prostheses. You need to understand that

 

​You cannot use the following code(s) ... ​​with these codes in the same claim (CMS will deny as not reasonable and necessary!)
​​L5500, L5510-L5530, or L5540 ​L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962 and L5980
L5535 L5620, L5629, L5645, L5646, L5670, L5676, L5704 and L5962
L5505, L5560-L5580, or L5590-L6500 ​L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, L5710-L5780, L5970-L5795
​​L5585 ​​L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964, and L5966
 

 

Feet

The LCD states that "the treating physician and/or the prosthetist" will determine the appropriate foot "based upon the functional needs of the beneficiary." This simple sentence, which also appears in the LCD under the next topic (Knees), highlights two of the key audit/prepayment claim review pressure points:
  1. the role the physician plays in the prosthetic claim process (always get corroborating documentation); and
  2. you have to thoroughly document the patient's functional needs (which would correlate directly to functional level).
The LCD then provides you a map linking specific foot codes to functional levels. Specifically:
  • L5970, L5974: covered for K1 or higher.
  • L5972, L5978: covered for K2 or higher.
  • L5973, L5976, L5979, L5980, L5981, L5987: covered for K3 or higher.
If you ignore the LCD and use a K3 code for a K2 patient, or a K2 code for a K1 patient, Medicare will deny it and you WILL lose the appeal.

The "Feet" section closes with the reminder that L5990 will be denied as not reasonable and necessary.

Knees

As in the "Feet" section, Medicare maps codes to functional level:
  • ​L5930: covered only for patients who are K4.
  • L5610, L5613, L5614, L5722-L5780, L5814, L5822-L5840, L5848, L5856, L5857, L5858: covered for K3 or higher.
  • L5611, L5616, L5710-L5718, L5810-L5812, L5816, L5818: covered for K1 or higher.
The section also has specific coverage criteria for L5859, the L-code created by Medicare to describe the function provided by Ossur's POWER KNEE. They are:
  1. ​The knee described by L5859 must also have all of the functionality described by L5856 (swing and stance phase control);
  2. K3 user;
  3. Patient weight between 110-275 lbs.
  4. Documented comorbidity of spine and/or sound limb affecting hip extension or quadriceps function impairing K3 functional level;
  5. Patient must be able to use a product that requires daily charging; and
  6. Is able to understand and respond to error alerts and alarms from the device.
Ankles
  • L5982-L5986: covered for K2 or higher.
Hips
  • L5961: covered for K3 or higher.
Sockets

The LCD states that unless your record documents a specific need for more than 2 test sockets (L5618-L5628) per prosthesis, Medicare will deny them as not reasonable and necessary. It also notes. (It goes without saying that you can't automatically bill 2 test sockets per prosthesis. If you fit a patient but only use 1 test socket, you can only bill Medicare for a single test socket. And if you do fit 2, your records need to clearly reflect that.)

The LCD further states that for immediate post-operative prostheses (L5400-L5460), test sockets are not reasonable and necessary. (In other words, Medicare will deny them.)

You must also remember that Medicare does not permit billing more than 2 of the same socket inserts (L5654-L5665, L5673, L5679, L5681, L5683) at the same time.

This section concludes with a non-inclusive list of factors that might warrant socket replacement:
  1. residual limb changes;
  2. functional need changes;
  3. irreparable damage or wear/tear resulting from either excessive patient weight or very active amputees.
Take a deep breath. Exhale. You've gotten through the largest section of the Lower Limb Prostheses LCD. In part 4 of this series, we will turn to documentation requirements.



Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com