Reimbursement Page
Code
Correctly and Get
Paid: Lower-Limb Prostheses
By Virginia Torsch
A large part of our job here at AOPA is to help you sort through the often confusing DMERC medical policy so you can get paid for the devices you provide.
Coverage policies are established for lower-limb prosthetics, orthopedic footwear, AFOs/KAFOs, spinal orthoses and therapeutic shoes for persons with diabetes.
In the March 2006 O&P Almanac I walked you through the medical policy for AFOs and KAFOs. This article covers the medical policy for lower-limb prostheses.
What is medical policy?
As a reminder, the format of medical coverage policies has changed from the more familiar local medical review policy (LMRP) to two separate documents—a local coverage determination (LCD) and an accompanying policy article.
The LCD discusses coverage in terms of medical necessity—is an item reasonable and medically necessary?
The LCD also contains the list of HCPCS codes and modifiers it covers, the ICD-9 diagnosis codes that support medical necessity for the items or services, the documentation requirements and a history of all revisions to the medical coverage policy since its inception.
The policy article identifies situations where an item is not covered by a Medicare benefit category—denied as “non-covered” rather than “not medically necessary.” It also identifies situations when an item may be denied as “not separately payable.”
Since different aspects of policy guidance about the same service or component are found in both documents, it’s tough to grasp when a lower-limb prosthesis will be paid by Medicare.
A medically necessary device?
Let’s start with the basics. Medicare will pay for a lower-limb prosthesis when the patient:
Medicare has also determined that, under certain circumstances, there are certain types of additions to the basic prosthesis that are not medically necessary and will not be reimbursed.
For example, when you provide an initial below-knee prosthesis that is described by L5500 or a preparatory below-knee prosthesis described by L5510-L5530 or L5540, you cannot use codes L5629 (acrylic socket), L5704 (custom shaped protective cover) or L5980 (flex-foot system). According to Medicare, these additions are inappropriate for the initial/preparatory device.
The sidebar Inappropriate Addition Codes for BK/AK Base Codes has a complete list of the addition codes you cannot use with initial or preparatory below- or above-knee prostheses.
Substituting components
To substitute or add a component to the basic prosthetic leg, the component must be medically necessary for the patient’s functional level. These codes must have the appropriate modifier, and you must clearly document your justification for the functional level in your records.
Feet. Per Medicare, these types of feet require a minimum functional level of:
Knees. Per Medicare, these types of knees require a minimum functional level of:
The specifics on sockets
Be aware of the limitations on sockets. Medicare will pay for two test sockets (L5618-L5628) unless you can clearly document why more than two are medically necessary.
Medicare will not pay for a test socket for immediate post-surgical rigid dressings (L5400-5460). Medicare also will not pay for more than two of the same socket inserts (L5654-L5665, L5673, L5679, L5681 or L5683) per prosthesis at the same time.
Medicare also has special coding guidelines for sockets. These can be confusing, so give close attention to the description of the code.
For example, L5671 describes both the part of the suspension locking mechanism that is integrated into the prosthesis socket and the pin, lanyard, or other component attached to the socket insert, but it specifically excludes the socket insert itself. So use L5673, L5681 or L5683 for socket inserts used in conjunction with L5671, depending on whether the prosthesis is initial or definitive and depending on the cause of amputation.
Medicare only allows you to use L5681 or L5683 with the initial issue of a custom fabricated socket insert. Additional inserts (either custom fabricated over an existing model or prefabricated) provided at the time of initial issue of the socket or replacement socket insert are coded L5673 or L5679, whichever is applicable.
Medicare does not allow you to bill L5647 or L5652 with L5671. L5671 represents a mechanical means of suspension such as a lock or lanyard. L5647 and L5652 describe suction sockets. Medicare has determined that billing for suction and a mechanical means of suspension on the same prosthesis is redundant.
And Medicare does not allow you to use L5647 (suction socket) or L5652 (above knee or knee disarticulation socket) with the codes for gel liners (L5673, L5679, L5681, L5683).
Adjustments and repairs
There are only certain repairs and adjustments for which Medicare will pay. For example, Medicare will not pay for labor or repairs due to normal wear and tear within 90 days of delivery. This is considered to be included in the reimbursement amount for the prosthesis. Medicare also does not cover routine periodic servicing such as testing, cleaning or checking the prosthesis.
However, Medicare will pay for adjustments required due to a change in the patient’s physical condition (e.g., weight loss, volume change in residual limb, etc.) without regard to the 90 day period following delivery.
After 90 days, you can bill Medicare for minor adjustments and repairs caused by wear without having to get a new order from the referring physician. Maintenance that may be necessary by the manufacturer’s recommendations or the construction of the prosthesis is also covered as a repair.
Use L7510 for repairing or replacing minor parts that do not have a specific L code for a replacement.
Use L7520 for the time it takes you to make the repairs or adjustments, but only for the time to make the repair. Note, though, that you cannot use L7520 for any evaluation time you had to spend. Use one unit of L7520 for every 15 minutes of labor.
Replacements
Medicare will pay for replacement of a major component (foot, knee, ankle or socket) or the entire prosthesis if there is a change in the patient’s physiological condition; if there has been irreparable wear to the prosthesis, or if repairs to the prosthesis would cost more than 60 percent of the cost of a new prosthesis.
Generally, you’ll need a new order from the referring physician. Exceptions are if you’re replacing the prosthesis or a major component because of loss or irreparable damage (not just damage from normal wear and tear) and the patient’s condition has not changed.
Use the RP modifier with the code of the component being replaced unless it is a socket. Socket replacements have their own codes, L5700-L5703, with descriptors that include the word “replacement,” so no RP modifier is necessary on these. You cannot charge for labor associated with replacing a component that has its own L code.
You don’t have to worry about useful lifetime restrictions for prostheses as you do for orthoses. However, Medicare has stated that replacement of prosthetic components less than three years old may result in a request for additional documentation to support the specific need for the replacement.
Hospital billing
The medical policy article accompanying the LCD for lower-limb prostheses has confusing guidelines for when to bill the hospital or skilled nursing facility (SNF) versus when to bill the DMERC.
Prostheses are included in the hospital consolidated billing. So, if you provide a prosthesis to a patient for use while the patient is in the hospital, you bill the hospital.
However, if you deliver the prosthesis to the patient within two days of discharge—even if it is just so the patient can make sure it fits and the patient is only going to use the prosthesis at home—you should bill the DMERC. You must make sure the device is in fact delivered right before the patient is going home, and that the patient is not going to be using the device at all in the hospital.
And if for some reason the patient does not go home but is instead transferred to a SNF, then the hospital is responsible for payment of that prosthesis. So under these circumstances you would bill the hospital rather than your DMERC.
SNF billing
It is a different story for prostheses provided to patients under a Medicare Part A stay in a skilled nursing facility (SNF). Most prostheses, except for partial feet (L5000-L5020) and immediate post surgical rigid dressings (L5400 – L5460), are exempt from the consolidated billing for SNFs.
So if you provide a prosthesis to a patient who is in a SNF under a Medicare Part A stay, you bill the DMERC, not the SNF. (Exceptions to this are partial feet, rigid dressings and prosthetic socks, which are billed to the SNF.)
Visit this Web site for a list of the prosthetic codes that are exempt from the SNF consolidated billing: www. cms.hhs.gov/SNFConsolidatedBilling/02 m_2006Update.asp#TopOfPage. The file is located under the title “File 1—Part A Stay—Physician Services.”
Miscellaneous issues
There are a few miscellaneous policies you need to know. First, Medicare considers the codes that describe ultra-light materials (L5940 – L5960) to apply to the entire prosthetic system. The result is that you can only use these codes once even if you have multiple components made out of ultra-light material.
Second, Medicare will not cover a prosthetic donning sleeve (L7600) or the user-adjustable heel height feature (L5990). These are considered convenience items.
Get paid for your work
These are the major provisions of medical policy on lower-limb prosthetics that you need to know to be paid for your claims. CMS and the DMERCs also occasionally publish transmittals and bulletins amplifying the provisions in the LCDs and accompanying policy articles, so you should watch for those, too.
Medicare expects you to keep up with all of these, so it is wise to pay attention to your DMERC bulletins and transmittals. Know, too, that the AOPA staff is committed to keeping you up to speed on this information so you can be reimbursed appropriately for your work.
Virginia Torsch is the assistant director of reimbursement services for the American Orthotic & Prosthetic Association (AOPA). AOPA is a not-for-profit trade association providing O&P-specific business services and products for professionals. Through reimbursement, coding and compliance education, AOPA works to inform and support the practice of O&P for the entire profession. Questions? Call (571) 431-0876 or visit www.AOPAnet.org.
By Virginia Torsch
A large part of our job here at AOPA is to help you sort through the often confusing DMERC medical policy so you can get paid for the devices you provide.
Coverage policies are established for lower-limb prosthetics, orthopedic footwear, AFOs/KAFOs, spinal orthoses and therapeutic shoes for persons with diabetes.
In the March 2006 O&P Almanac I walked you through the medical policy for AFOs and KAFOs. This article covers the medical policy for lower-limb prostheses.
What is medical policy?
As a reminder, the format of medical coverage policies has changed from the more familiar local medical review policy (LMRP) to two separate documents—a local coverage determination (LCD) and an accompanying policy article.
The LCD discusses coverage in terms of medical necessity—is an item reasonable and medically necessary?
The LCD also contains the list of HCPCS codes and modifiers it covers, the ICD-9 diagnosis codes that support medical necessity for the items or services, the documentation requirements and a history of all revisions to the medical coverage policy since its inception.
The policy article identifies situations where an item is not covered by a Medicare benefit category—denied as “non-covered” rather than “not medically necessary.” It also identifies situations when an item may be denied as “not separately payable.”
Since different aspects of policy guidance about the same service or component are found in both documents, it’s tough to grasp when a lower-limb prosthesis will be paid by Medicare.
|
K Modifiers for Patient
Functional Levels
K0—Functional Level 0: The patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance the quality of life or mobility. K1—Functional Level 1: The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulatory. K2—Functional Level 2: The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulatory. K3—Functional Level 3: The patient has the ability or potential for ambulation with variable cadence. Typical of the community ambulatory who has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion. K4—Functional Level 4: The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels. Typical of the prosthetic demands of the child, active adult or athlete. |
A medically necessary device?
Let’s start with the basics. Medicare will pay for a lower-limb prosthesis when the patient:
- Will reach or maintain a defined functional state within a reasonable period of time, and
- Is motivated to ambulate.
- The patient’s past history (including prior prosthetic use);
- The patient’s current condition, including the status of the residual limb and the nature of other medical problems, and
- The patient’s desire to ambulate.
Medicare has also determined that, under certain circumstances, there are certain types of additions to the basic prosthesis that are not medically necessary and will not be reimbursed.
For example, when you provide an initial below-knee prosthesis that is described by L5500 or a preparatory below-knee prosthesis described by L5510-L5530 or L5540, you cannot use codes L5629 (acrylic socket), L5704 (custom shaped protective cover) or L5980 (flex-foot system). According to Medicare, these additions are inappropriate for the initial/preparatory device.
The sidebar Inappropriate Addition Codes for BK/AK Base Codes has a complete list of the addition codes you cannot use with initial or preparatory below- or above-knee prostheses.
Substituting components
To substitute or add a component to the basic prosthetic leg, the component must be medically necessary for the patient’s functional level. These codes must have the appropriate modifier, and you must clearly document your justification for the functional level in your records.
Feet. Per Medicare, these types of feet require a minimum functional level of:
- K1 or higher for an external SACH foot (L5970) or single-axis ankle foot (L5974).
- K2 or higher for a flexible-keel foot (L5972) or multiaxial ankle/foot (L5978).
- K3 or higher for a flex-foot system (L5980), energy-storing foot (L5976), multiaxial ankle/foot, dynamic response (L5979), flex-walk system or equal (L5981) or shank foot system with vertical loading pylon (L5987).
Knees. Per Medicare, these types of knees require a minimum functional level of:
- K1 or higher for knee systems described by L5611, L5616, L5710-L5718, L5810-L5812, L5816, or L5818.
- K3 or higher for fluid, pneumatic, or electronic knees described by L5610, L5613, L5614, L5722-L5780, L5814, L5822-L5840, L5848, L5856, L5857 or L5858.
- K4 for a high-activity knee control frame (L5930).
- K2 or higher for an axial rotation unit (L5982-L5986).
|
Inappropriate Addition Codes for
BK Base Codes
|
|
| Initial (L5500) or preparatory (L5510-L5530, L5540) | Cannot use L5629, L5638, L5639, L5646, L5647, L5704, L5785, L5962 and L5980 |
| Preparatory or prefabricated (L5535) | Cannot use L5620, L5629, L5645, L5646, L5670, L5676, L5704 and L5962 |
| Inappropriate Addition Codes for AK Base Codes | |
| Initial (L5505) or preparatory (L5560-L5580, L5590-L5600) | Cannot use L5610, L5631, L5640, L5642, L5644, L5648, L5705, L5706, L5964, L5980, L5710-L5780 and L5790-L5795 |
| Preparatory or prefabricated (L5585) | Cannot use L5624, L5631, L5648, L5651, L5652, L5705, L5706, L5964 and L5966 |
The specifics on sockets
Be aware of the limitations on sockets. Medicare will pay for two test sockets (L5618-L5628) unless you can clearly document why more than two are medically necessary.
Medicare will not pay for a test socket for immediate post-surgical rigid dressings (L5400-5460). Medicare also will not pay for more than two of the same socket inserts (L5654-L5665, L5673, L5679, L5681 or L5683) per prosthesis at the same time.
Medicare also has special coding guidelines for sockets. These can be confusing, so give close attention to the description of the code.
For example, L5671 describes both the part of the suspension locking mechanism that is integrated into the prosthesis socket and the pin, lanyard, or other component attached to the socket insert, but it specifically excludes the socket insert itself. So use L5673, L5681 or L5683 for socket inserts used in conjunction with L5671, depending on whether the prosthesis is initial or definitive and depending on the cause of amputation.
Medicare only allows you to use L5681 or L5683 with the initial issue of a custom fabricated socket insert. Additional inserts (either custom fabricated over an existing model or prefabricated) provided at the time of initial issue of the socket or replacement socket insert are coded L5673 or L5679, whichever is applicable.
Medicare does not allow you to bill L5647 or L5652 with L5671. L5671 represents a mechanical means of suspension such as a lock or lanyard. L5647 and L5652 describe suction sockets. Medicare has determined that billing for suction and a mechanical means of suspension on the same prosthesis is redundant.
And Medicare does not allow you to use L5647 (suction socket) or L5652 (above knee or knee disarticulation socket) with the codes for gel liners (L5673, L5679, L5681, L5683).
Adjustments and repairs
There are only certain repairs and adjustments for which Medicare will pay. For example, Medicare will not pay for labor or repairs due to normal wear and tear within 90 days of delivery. This is considered to be included in the reimbursement amount for the prosthesis. Medicare also does not cover routine periodic servicing such as testing, cleaning or checking the prosthesis.
However, Medicare will pay for adjustments required due to a change in the patient’s physical condition (e.g., weight loss, volume change in residual limb, etc.) without regard to the 90 day period following delivery.
After 90 days, you can bill Medicare for minor adjustments and repairs caused by wear without having to get a new order from the referring physician. Maintenance that may be necessary by the manufacturer’s recommendations or the construction of the prosthesis is also covered as a repair.
Use L7510 for repairing or replacing minor parts that do not have a specific L code for a replacement.
Use L7520 for the time it takes you to make the repairs or adjustments, but only for the time to make the repair. Note, though, that you cannot use L7520 for any evaluation time you had to spend. Use one unit of L7520 for every 15 minutes of labor.
Replacements
Medicare will pay for replacement of a major component (foot, knee, ankle or socket) or the entire prosthesis if there is a change in the patient’s physiological condition; if there has been irreparable wear to the prosthesis, or if repairs to the prosthesis would cost more than 60 percent of the cost of a new prosthesis.
Generally, you’ll need a new order from the referring physician. Exceptions are if you’re replacing the prosthesis or a major component because of loss or irreparable damage (not just damage from normal wear and tear) and the patient’s condition has not changed.
Use the RP modifier with the code of the component being replaced unless it is a socket. Socket replacements have their own codes, L5700-L5703, with descriptors that include the word “replacement,” so no RP modifier is necessary on these. You cannot charge for labor associated with replacing a component that has its own L code.
You don’t have to worry about useful lifetime restrictions for prostheses as you do for orthoses. However, Medicare has stated that replacement of prosthetic components less than three years old may result in a request for additional documentation to support the specific need for the replacement.
|
Links to Medicare Local Coverage
Determinations (LCDs) and Policy Articles
DMERC A:www.tricenturion.com/content/lmrp_current_dyn.cfm DMERC B: www.adminastar.com/Providers/DMERC/MedicalPolicy/DMERC_ CurrentLMRPs.cfm DMERC C: www.cms.hhs.gov/mcd/results_index.asp?from=’lmrpstate’&contractor= 93&name=Palmetto+GBA+%2800885%29+%2D+DMERC&letter_range=4 DMERC D: www.cignamedicare.com/dmerc/lmrp_lcd/index.html |
Hospital billing
The medical policy article accompanying the LCD for lower-limb prostheses has confusing guidelines for when to bill the hospital or skilled nursing facility (SNF) versus when to bill the DMERC.
Prostheses are included in the hospital consolidated billing. So, if you provide a prosthesis to a patient for use while the patient is in the hospital, you bill the hospital.
However, if you deliver the prosthesis to the patient within two days of discharge—even if it is just so the patient can make sure it fits and the patient is only going to use the prosthesis at home—you should bill the DMERC. You must make sure the device is in fact delivered right before the patient is going home, and that the patient is not going to be using the device at all in the hospital.
And if for some reason the patient does not go home but is instead transferred to a SNF, then the hospital is responsible for payment of that prosthesis. So under these circumstances you would bill the hospital rather than your DMERC.
SNF billing
It is a different story for prostheses provided to patients under a Medicare Part A stay in a skilled nursing facility (SNF). Most prostheses, except for partial feet (L5000-L5020) and immediate post surgical rigid dressings (L5400 – L5460), are exempt from the consolidated billing for SNFs.
So if you provide a prosthesis to a patient who is in a SNF under a Medicare Part A stay, you bill the DMERC, not the SNF. (Exceptions to this are partial feet, rigid dressings and prosthetic socks, which are billed to the SNF.)
Visit this Web site for a list of the prosthetic codes that are exempt from the SNF consolidated billing: www. cms.hhs.gov/SNFConsolidatedBilling/02 m_2006Update.asp#TopOfPage. The file is located under the title “File 1—Part A Stay—Physician Services.”
Miscellaneous issues
There are a few miscellaneous policies you need to know. First, Medicare considers the codes that describe ultra-light materials (L5940 – L5960) to apply to the entire prosthetic system. The result is that you can only use these codes once even if you have multiple components made out of ultra-light material.
Second, Medicare will not cover a prosthetic donning sleeve (L7600) or the user-adjustable heel height feature (L5990). These are considered convenience items.
Get paid for your work
These are the major provisions of medical policy on lower-limb prosthetics that you need to know to be paid for your claims. CMS and the DMERCs also occasionally publish transmittals and bulletins amplifying the provisions in the LCDs and accompanying policy articles, so you should watch for those, too.
Medicare expects you to keep up with all of these, so it is wise to pay attention to your DMERC bulletins and transmittals. Know, too, that the AOPA staff is committed to keeping you up to speed on this information so you can be reimbursed appropriately for your work.
Virginia Torsch is the assistant director of reimbursement services for the American Orthotic & Prosthetic Association (AOPA). AOPA is a not-for-profit trade association providing O&P-specific business services and products for professionals. Through reimbursement, coding and compliance education, AOPA works to inform and support the practice of O&P for the entire profession. Questions? Call (571) 431-0876 or visit www.AOPAnet.org.
