Medicare Policy FAQs
by Joe McTernan, AOPA Government Affairs Department

This month’s “Ask the Expert” will focus on questions about Medicare coverage policies that AOPA’s reimbursement staff answers frequently. While the discussion below by no means represents a comprehensive guide to Medicare policy, it does represent the most common requests for clarification we receive.

Q: Will Medicare cover roll-on type prosthetic liners described by L5673, L5679, L5681 or L5683 when a patient is provided with an initial or preparatory prosthesis?

A: The Medicare Lower Limb Prosthesis Local Coverage Decision (LCD) permits the use of these codes in conjunction with initial or preparatory prosthesis base procedure codes. As long as medical necessity criteria exist that support the use of roll-on prosthetic liners, Medicare will cover up to two liners per prosthetic limb, including initial and preparatory prostheses.

Q: What addition codes are not permitted to be billed with initial and temporary base prosthesis procedure codes?

A: According to the LCD, the following codes may not be billed in conjunction with an initial below-knee prosthesis (L5500) or a preparatory below-knee prosthesis (L5510-L5530, L5540): L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962 and L5980. These codes will be denied as not medically necessary.

When billing for a below-knee prefabricated preparatory prosthesis (L5535), you may not bill for the following addition codes: L5620, L5629, L5645, L5646, L5670, L5676, L5704 and L5962.

For above-knee initial (L5505) or preparatory (L5560-L5580, L5590-L5600) prostheses, the following codes will be denied as not medically necessary: L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, L5710-L5780 and L5790-L5795.

When providing an above-knee prefabricated prosthesis, the following codes will be denied as not medically necessary: L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964 and L5966.

Q: Are shoe inserts ever covered by Medicare other than for diabetic patients?

A: Yes. Shoe inserts are covered by Medicare when they are designed to be worn inside of a shoe that is an integral part of a leg brace. Since Medicare covers the shoe in this circumstance, it will also pay for any inserts that are required for the shoe to perform properly. Claims for shoes and inserts that are an integral part of a brace should include a KX modifier indicating that coverage criteria have been met.

Q: Why does Medicare not cover AFOs that are used to treat or prevent pressure ulcers?

A: The Medicare AFO/KAFO LCD states that when an AFO (or KAFO) is used solely to treat or prevent pressure ulcers, it will be denied as non-covered/no benefit because it does not meet the definition of a brace when used for wound treatment.

For Medicare purposes, a brace is defined as a device that supports a weak or deformed body member, or a device that restricts or eliminates motion in a diseased or injured body part.

Q: Will Medicare cover a replacement orthosis if it has been less than five years since the original orthosis was provided?

A: Sometimes. Medicare policy states that in absence of specific designation by the Secretary of Health and Human Services, the useful lifetime of any DMEPOS item is no less than five years. This means that if an orthosis less than five years old needs to be replaced due to normal wear and tear, Medicare will not cover the replacement.

If the need for replacement is due to loss, theft, irreparable damage or a change in patient condition that causes the orthosis to no longer be effective, Medicare will cover the replacement. If you replace a device for one of these reasons, you should be able to document the specific reason for the replacement.

Q: What about replacement prostheses?

A: The Benefits Improvement Act of 2000 (BIPA) legislatively exempted prosthetic devices from the five-year “useful lifetime” restriction. Prosthetic devices are eligible for replacement upon the order of a physician, subject to regular medical necessity criteria.

The law states that if a prosthetic device is replaced within three years from the date of provision of the original prosthesis, the provider can expect to be asked to submit additional documentation supporting the need for the replacement.

Q: Can I bill Medicare for a device on which work was started, but could not be delivered due to the death of the patient?

A: Yes, if it is a custom device. Medicare regulations state that if a custom orthosis or prosthesis was ordered, but could not be delivered for one of the reasons below, the provider may be reimbursed for the value of the device minus any salvageable components or portions that had yet to be completed.

The acceptable reasons are as follows:

•    Patient death.
•    A change in patient condition that renders the device no longer appropriate for the patient’s condition.
•    The patient cancels the order.

When one of these situations occurs, you may submit your claim using a date of service matching any of the following: the date of death, the date that you learned of the condition change or the date the order was cancelled. This exception does not apply to prefabricated devices, since they can be reused.

As always, we encourage AOPA members to contact the reimbursement staff with any questions you may have regarding Medicare coverage issues. For more information, contact Joe McTernan at (571) 431-0876, ext.211, or jmcternan@AOPAnet.org.

Joe McTernan is director of reimbursement services for AOPA.