LCD and Policy Article Revisions Summary for July 18, 2024 - JA DME

Joint DME MAC Publication
Posted July 18, 2024

Outlined below are the principal changes to the DME MAC Local Coverage Determination (LCD) and Policy Articles (PAs) that have been revised and posted. The policies included are Intravenous Immune Globulin and Lower Limb Prostheses. Please review the entire LCDs and related PAs for complete information.

Intravenous Immune Globulin

PA

Revision Effective Date: 01/01/2024
CODING GUIDELINES:
Added: Direction for billing ALYGLO (immune globulin intravenous, human-stwk) effective for dates of service on or after December 15, 2023

07/18/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Lower Limb Prostheses

LCD

Revision Effective Date: 09/01/2024
COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:
Revised: Coverage criteria for microprocessor-controlled ankle foot system, energy storing foot, dynamic response foot with multi-axial ankle, flex foot system, flex-walk system or equal, and shank foot system with vertical loading pylon, to include coverage for beneficiaries whose functional level is 2 when specified criteria are met
Revised: Coverage criteria for a fluid or pneumatic knee unit, control addition fluid, and electronic/microprocessor-controlled knee system, to include coverage for beneficiaries whose functional level is 2 when specified criteria are met
SUMMARY OF EVIDENCE:
Added: Information related to microprocessor-controlled prosthetic knees
ANALYSIS OF EVIDENCE:
Added: Information related to microprocessor-controlled prosthetic knees
BIBLIOGRAPHY:
Added: Information related to microprocessor-controlled prosthetic knees
CODING INFORMATION:
Added: GA, GY, GZ, and KX modifiers
RELATED LOCAL COVERAGE DOCUMENTS:
Added: Response to Comments article (A59857)

PA

Revision Effective Date: 09/01/2024
FUNCTIONAL LEVEL CHARACTERISTICS:
Added: Section header and functional level characteristics information
POLICY SPECIFIC DOCUMENTATION REAUIREMENTS:
Added: Information which specifies that orthotist and prosthetist records are considered part of the medical record to support documentation created by the treating practitioner
Added: L5615 and L5841 to the HCPCS codes referenced in regard to claims for knee, foot, ankle, and hip components
Added: Information that must be included in the medical records for certain HCPCS codes (L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5856, L5857, L5858) for beneficiaries whose functional level is 2
MODIFIERS:
Revised "LT and RT MODIFIERS:" to "GA, GY, GZ, KX, LT, and RT MODIFIERS:"
Added: Information which pertains to inclusion of the KX, GA, GY, or GZ modifier on claims
Added: GY modifier usage when billing for a prosthetic donning sleeve (L7600)
Removed: "(refer to the CODING GUIDELINES section for additional information)" in regard to RT and LT modifiers
Added: RT and LT modifier information (relocated from the CODING GUIDELINES section)
CODING GUIDELINES:
Revised: The layout and content located within "PROSTHETIC SYSTEMS," including addition of "Immediate Post Op" with relevant information, "Preparatory" with relevant information, "Initial" with relevant information, "Exoskeletal" with relevant information, and "Endoskeletal" with relevant information
Added: "Prosthetic system codes should not be used when billing a replacement socket for an existing prosthesis."
Removed: "L5301, L5540, L5321, L5590 should not be used when billing a replacement socket for an existing prosthesis."
Removed: "The use of L5301, L5540, L5321, L5590 with a replacement socket is incorrect coding (unbundling)."
Added: "Replacements" with relevant information
Added: "The use of the prosthetic system codes with a replacement socket is incorrect coding (unbundling)."
Revised: "The beneficiary may qualify for an upgraded knee-shin system depending on their assigned K-level modifier (K0-K4), as referenced in the LCD." to "The beneficiary may qualify for an upgraded knee-shin system depending on their assigned K-level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD."
Revised: HCPCS codes referenced as addition codes for endoskeletal knee-shin systems that are considered an upgrade to the knee-shin system, to include L5615 and L5841
Revised: "The beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4), as referenced in the LCD." to "The beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD."
Revised: HCPCS codes referenced as single addition codes that can fully describe complete knee-shin systems and for which the use of two codes would be considered incorrect coding, to include L5615 and L5841
Revised: "L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840)." to "L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, and L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, and L5841)."
Revised "The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4), as referenced in the LCD." and "The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD." to "The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD."
Revised: "The beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) as referenced in the LCD." to "The beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD."
Removed: RT and LT modifier information

07/18/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.

With the update(s) listed above, Noridian would like to remind users how to find the policy that was previously effective. When billing, the supplier should follow guidance that was effective on the date of service. The below steps can be followed to find all previous policies:

1. Open the currently effective policy on the Medical Coverage Database (MCD)
   1. Links to the MCD can be found on the Active LCDs page on the Noridian website
      1. There is a link at the top of the Active LCD page that goes to a full list of the LCDs or PAs, depending on which link is selected OR
      2. There are direct links to all LCDs under the 'LCD ID number and Effective Date' column
2. Scroll down to the bottom of the policy
3. Find the section labeled Public Version(s)
4. Look for the link to the policy that was effective on the dates of service in question.
5. Click on hyperlink to go to the policy.