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David McGill Blogger

The Coding Revolution

Posted by David McGill | February 05, 2013

MAC Regions A & B issued new guidance last Friday about how to appropriately bill microprocessor knee codes. We expect Regions C & D to follow suit in the very near future (if they haven't already between the time I sent this post to the web-overlords who help us with Össur R&R and the time it takes them to upload it onto the magical interweb).

The highlights of the MACs' guidance:

  • The following codes are the only ones that suppliers can use when billing Medicare for Össur's RHEO KNEE: L5856, L5828, L5845, L5848, L5930.
  • The following codes are the only ones that suppliers can use when billing Medicare for (a) Otto Bock's C-Leg, Genium, or X2, (b) Freedom's plié, (c) Endolite's Orion, and (d) DAW's SLK: L5856, L5828, L5845, L5848.
  • The following codes are the only ones that suppliers can use when billing Medicare for Endolite's Orion: L5857, L5848. [The MACs reference the Orion in two places with two different groups of codes (see first bullet, (c), above.]
  • The following codes are the only ones that suppliers can use when billing Medicare for Otto Bock's C-Leg Compact: L5858, L5828, L5845.
  • The MACs add that "the use of additional HCPCS codes other than those specified above, either specific codes or NOC [i.e., L5999) codes, for other add-ons, functions or features is considered unbundling and thus is incorrect coding. [Emphasis added]

What does this mean for you?

First, the MACs will now take the position that they have put all O&P suppliers on notice that correct billing for microprocessor-knees has to follow the above criteria. Failure to follow the MACs' guidance could put your business at risk not only for negative audit/pre-payment claims review results, but for more significant liability under the False Claims Act.

Second, this new guidance, together with the recent notice from Region D that it is conducting a widespread prepayment claims review of all claims using L5980, L5981, and L5987 (see our January 28 post), suggests that Medicare and its contracting entities are increasingly interested in getting down to the product level when reviewing claims. With this kind of scrutiny, suppliers must take care to only bill those codes that clearly apply to the product being delivered. Otherwise, they may become casualties of the coding revolution.

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