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David McGill Blogger

Back to Basics: The Prosthetic LCD (Part 4)

Posted by David McGill | August 22, 2013

The LCD's final section, "General Information," lists 4 important ​Medicare requirements.

1. Prescription (Order) Requirements


The LCD sets forth 3 prescription (or order) requirements. First, For every item you bill to Medicare, you must have a doctor's prescription on file.

Second, you may deliver supplies upon receipt of a dispensing order (written or verbal) so long as it contains (a) a description of the item, (b) the beneficiary's name, (c) the prescribing physician's name, and (d) date of the order (and start date, if different from order date). Note: Medicare prohibits signature and date stamps.

Third, you must obtain a detailed written order before filing the claim. The DWO must include (a) the beneficiary's name, (b) the doctor's name, (c) date of the order (and start date, if different from order date), (d) detailed description of the item, and (e) physician signature and date of signature. Again, signature and date stamps are prohibited. 

One additional points about DWOs: someone other than the ordering physician can produce it (i.e., you).

This section of the LCD ends with one final reminder: the prescription is not part of the medical record.

2. Medical Record Information

This section begins with the statement that "supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g., letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. [emphasis added] It goes on to say that "[r]ecords from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary."

From there, the LCD turns to the issue of proof of delivery. The key elements of adequate proof of delivery are:


  • evidence that you properly coded what you delivered;
  • the items you delivered are the same as what you billed Medicare for;
  • a specific Medicare beneficiary received the items; and
  • a legible beneficiary (or designee) signature and date.
The LCD then runs through 3 different delivery scenarios that you must familiarize yourself with: delivery directly to the beneficiary; delivery via shipping; and delivery to a nursing facility.

3. Repair and Replacement

The LCD briefly touches on this subject, pointing out that adjustments and repairs are not separately payable, as the original order covers such work. On the other hand, if you want to replace an entire prosthesis or major part of one (foot, ankle, knee, socket), you must obtain a new doctor's order for it.

Listed reasons for possible replacement include but aren't limited to: residual limb changes; functional need changes; or irreparable damage or wear/tear due to excessive patient weight or demands of high-activity patients.


4. Policy Specific Documentation Requirements

The final section of the LCD lists prosthetic codes that require K level modifiers​, and emphasizes that entering a K level without explanation fails to meet Medicare's requirements. Rather, "[t]here must be information about the beneficiary's history and current condition which supports the designation of the functional level by the prosthetist."

The LCD closes with a reminder that for L5859, the medical records "should describe the nature and extent of the comorbidity of the spine or the sound limb which is what is limiting this beneficiary to a household ambulator, and clearly document how this feature will enable the beneficiary to function as a community ambulator."


And that, dear readers, brings us to the end of our "Back to Basics" review of the Lower Limb Prostheses LCD. This is the foundation upon which you must build every Medicare claim you file. 

We hope you found this series useful.

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