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Prepayment Review of HCPCS L5856 Announced by Region C

Posted by Linda Collins | May 04, 2017

DME MAC, Region C, announced they will begin a wide spread prepayment review of all claims with HCPCS L5856. The review will begin in June.

What does this mean for you?

When you submit a claim with L5856 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE)  you will receive an Additional Documentation Request (ADR) letter. At this point, you have 45 days to respond by providing all the documentation for that particular claim. Once Region C receives the documentation, they will review for completeness. If required elements are missing or documentation is incomplete, the claim may be denied.

In preparation for this review, we suggest the following:

  • Review the Local Coverage Determination/Policy Article.
  • Gather all your documentation, including DWO, corroborating physician notes, PODs and chart notes prior to delivery of prosthesis.
  • Provide detailed description of the patient's activities, medical condition, and desire to ambulate in your medical records.
  • Make sure the physician's notes corroborate your findings (activities, medical condition, functional level.) You can use the Physician Worksheet for Prosthetic Documentation to facilitate discussions with the doctor. 
  • Include the product manufacturer and model number on your Proof of Delivery.
  • Respond immediately to an ADR. You do have 45 days from the date of the letter, but delays in response mean delays in payment to you.
  • Sign up for access to MyCGS so you can track your ADR submissions.
  • Check your documentation for completeness. Use the Lower Limb Prosthesis Documentation Checklist as a guide.
  • Remember, The Audit Team, offers a Quality Assurance document review for your Medicare claims, which include Össur products. Contact Stephane Greene at 330-209-4543 for more information.

As Region C releases more information about this audit, we will keep you posted.

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If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]