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David McGill Blogger

New MAC Coding Guidance Re. L5930

Posted by David McGill | October 07, 2016

​The DME MACs issued a joint publication yesterday afternoon regarding the appropriate L codes to use when billing Otto Bock's C-Leg. However, certain elements of the guidance apply to all prosthetic knee claims. Here's what you need to know:

  1. ​The most critical aspect of the new coding guidance centers on L5930 (high activity knee frame). 

  2. Relevant History: Beginning in 2006, the MACs updated the LCD for lower limb prosthetics to state that L5930 can only be used for individuals classified as functional level K4. As a result, some suppliers have billed C-Leg with L5930 for their K4 patients and without it for K3 individuals, even though the product delivered to the patient is exactly the same in both instances.

  3. The New Guidance: The MACs now have stated that "All HCPCS codes assigned to a product must always be billed. The practice of partial billing of selected codes, for any product [emphasis added], is incorrect coding. As discussed above, L5930 is no longer assigned to the C-Leg and must not be billed for this product, regardless of which K-level is assigned."

  4. Less critical but still important to point out, the new directive also prohibits billing L5920 (alignable system), L5950 (ultra-light material) and L5999 for C-Leg claims.

What does this mean for you?

The most important element of the new coding guidance is the MACs' prohibition on what they describe as the practice of "partial billing of selected codes." A simpler way of saying this is that when you file a Medicare claim, the MACs expect you to bill the same component the same way every time. So under this new guidance, billing a microprocessor-controlled knee with 4 codes for K3 amputees but with 5 codes (adding L5930) for K4 amputees would not be appropriate.

We anticipate that some may interpret the new MAC guidance as limited only to those products that have undergone formal reviews by either the PDAC or HCPCS Coding Workgroup (based upon the words, "assigned to a product," which arguably implies review by one of those two coding bodies). So, that logic goes, any product not reviewed by the PDAC or HCPCS Coding Workgroup would not be subject to this directive. 

While we acknowledge that this could be a legitimate interpretation of the new guidance, it strikes us as at odds with the overall tenor of the joint publication from the DME MACs. In particular, the release includes the language "for any products," which implies that they intended for this principle to extend beyond the specific product at issue in yesterday's guidance. As a result, as of the date of this R&R post, Össur no longer suggests L5930 for any of its microprocessor-controlled knees. We are updating online and physical guides, brochures, and other written materials accordingly. 

Of secondary importance, the new guidance from the MACs also prohibits billing L5920 (alignable system) and L5950 (ultra-light material) in conjunction with the C-Leg on the ground that the other L codes already describe that device in its entirety. While that guidance is, on its face, limited to the C-Leg, the underlying logic would​​ again appear to extend to other devices. Össur has not and still does not suggest either of those codes for any of its microprocessor-controlled knees, but we encourage anyone using those codes for other devices to revisit the issue in light of this new guidance.

We will continue to monitor this situation as events develop and provide new posts on the topic as events warrant.

Össur R&R

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