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David McGill Blogger

Huge Changes for Prosthetics? The New Draft LCD

Posted by David McGill | July 17, 2015

​Yesterday the DME MACs released ​a new draft LCD for lower limb prostheses that could replace the current one. The ramifications are potentially far reaching. It is not an exaggeration to say that this might be the most significant change to prosthetic billing and coverage requirements since the creation of the L codes if the draft were implemented in its current form.

The draft LCD has too many changes to easily address in a single post, but we want to flag a preliminary "top 10" from that document. (For ease of reference, our Top 10 list is in the same order these items are discussed in the draft LCD. Please also note that this is not a comprehensive list of the proposed changes.)

#1: New Definitions

The draft LCD creates new definitions for numerous terms, including "immediate prosthesis,"  "preparatory prosthesis," "definitive prosthesis," "replacement prosthesis," and "Licensed or Certified Medical Professional" (which refers to non-suppliers qualified to perform functional assessments of amputees).

#2: The 3 Types of Prosthetics

The draft LCD prohibits the use of any add-on codes for Immediate (Post-Operative) Prostheses and Preparatory Prostheses. It would also deny "all related additions" if any part of any type of prosthesis is denied as not reasonable and necessary.​

#3: Socket Code Restrictions

The draft LCD limits the use of certain codes when billing for sockets. For example, L5637 and L5650 (total contact) would be denied as unbundling when billed for a molded socket design. Similarly, it would prohibit billing L5668 (molded distal cushion) for any patient using "a liner or insert that incorporates materials that provide cushioning."

#4: Say Goodbye to Elevated Vacuum Systems

The draft LCD declares L5781 and L5782 "not reasonable and necessary" due to lack of sufficient clinical evidence.

#5: Major Foot Code Changes

The draft LCD collapses L5980, L5981, and L5987 into one new code generically describing "dynamic response" feet.

#6: Axial Rotation Code Changes

The draft LCD collapses L5982, L5984 and L5986 into one new code generically describing an "axial rotation unit, with or without adjustability."

#7: Fixed-Ankle Feet Only for K1 and K2 Patients

The draft LCD restricts L5968 to K3 or higher users.

#8: Prosthetic Cover Restrictions

The draft LCD formalizes previous MAC guidance classifying L5962, L5964 and L5966 ("flexible protective outer surface covering" codes) as "rarely necessary," with the sole exception being instances where the user has "special needs for protection against unusually harsh environmental situations."

#9: K Level Overhaul

The draft LCD eliminates any analysis of the patient's "potential" functional level, restricting the K level analysis solely to the patient's actual ability at the time of assessment. It also would automatically make any patient using a walker or crutches a K1 user and any patient using a cane a K2 user.

#10: In-Person Physician Patient Examination Required

The draft LCD requires any patient receiving a definitive prosthesis to undergo an in-person examination by the physician before the physician signs the detailed written order. In addition, the physician must both provide a copy of her examination to the prosthetist within 45 days of its occurrence and do so before delivery of the prosthesis. The LCD also lists a comprehensive set of findings that must be included in the in-person examination report.

What does this mean for you?

If implemented, these changes could have a profound impact on how you code certain items and how your business operates. We therefore recommend you do 3 things immediately.

First, review the draft LCD in its entirety. As noted above, our "top 10" is not a comprehensive list of all the proposed changes. While we think that the ones we have discussed in this post are among the most important, it is possible that other changes could have a particularly significant impact on your specific business. You can link to the draft LCD here - . (In the interest of simplicity, we are not linking to each individual DME MAC because the draft LCD is identical for all 4 Regions.)

Second, after you identify the potential changes that you think could have the biggest effect on your business, do hard research based on your historical practices to try to quantify their impact. It's not enough to say, "These X things will make things more difficult for us!" You have to then model the potential ramifications​ so that you can develop appropriate contingency plans.

Third, make sure to closely follow key O&P organizations like NAAOP and AOPA to see how you and your patients can participate in the draft LCD comment process. The MACs are taking comments on the draft LCD until August 31st. There has never been a time where your involvement and input will be more important to the future of the O&P profession. Engage!

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