Correct Coding - Otto Bock C-Leg Coding - Revised

DME MAC Joint Publication

Revised – October 6, 2016

Originally published July 14, 2008 and revised January 31, 2013 under the title Correct Coding and Billing for Electronic/Microprocessor-Controlled Knee (MPK) Systems.

The Otto Bock C-Leg is a microprocessor controlled prosthetic knee. The product is covered by Medicare for beneficiaries classified as K-level 3 or 4. The most recent HCPCS code determination for Medicare billing purposes was posted to the PDAC Durable Medical Equipment Coding System Product Classification (DMECS PCL) List in 2005. This HCPCS coding determination has been re-evaluated at the company's request. Effective for claims with dates of service on or after the publication date of this article, only the following codes may be used to bill Medicare for this product:

  • L5828 - ADDITION, ENDOSKELETAL KNEE-SHIN SYSTEM, SINGLE AXIS, FLUID SWING AND STANCE PHASE CONTROL
  • L5845 - ADDITION, ENDOSKELETAL, KNEE-SHIN SYSTEM, STANCE FLEXION FEATURE, ADJUSTABLE
  • L5848 - ADDITION TO ENDOSKELETAL KNEE-SHIN SYSTEM, FLUID STANCE EXTENSION, DAMPENING FEATURE, WITH OR WITHOUT ADJUSTABILITY
  • L5856 - ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE

The PDAC DMECS PCL will be updated accordingly.

This group of four codes is all-inclusive i.e., they describe all features and functions of the C-Leg. Other HCPCS codes including L5920, L5930, L5950, and L5999 must not be used for Medicare billing of the C-Leg.

Historically, some suppliers have billed HCPCS code L5930 (ADDITION, ENDOSKELETAL SYSTEM, HIGH ACTIVITY KNEE CONTROL FRAME) for C-Legs provided to beneficiaries classified as K-level 4, while not billing this code for K-level 3. All HCPCS codes assigned to a product must always be billed. The practice of partial billing of selected codes, for any product, is incorrect coding. As discussed above, L5930 is no longer assigned to the C-Leg and must not be billed for this product, regardless of which K-level is assigned.

Refer to the Lower Limb Prosthesis LCD and related Policy Article for additional information.

For questions about correct coding, contact the Pricing, Data Analysis and Coding (PDAC) contractor Contact Center at (877) 735-1326 during the hours of 8:30 a.m. to 4:00 p.m. CT, Monday through Friday, or e-mail the PDAC by completing the DME PDAC Contact Form.

 

Last Updated Fri, 06 Dec 2019 12:12:01 +0000