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Lower Limb Prosthesis (HCPCS L5980, L5981, L5987) Final Edit Effectiveness Results of Service Specific Prepayment Review

The Jurisdiction D, DME MAC, Medical Review Department is conducting a service specific review of HCPCS code L5980, L5981 and L5987. The final edit effectiveness results from June 2015 through February 2016 are as follows:

The L5980 review involved 19 claims, of which 19 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 88%.

The L5981 review involved 51 claims, of which 46 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 81%.

The L5987 review involved 41 claims, of which 36 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 79%

Top Denial Reasons

Educational Resources

It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Lower Limb Prosthesis Local Coverage Determination (LCD) L33787 and Policy Article A52496.

Suppliers can also review specific policy resources for Orthotics and Prosthetics on the Noridian website. There, you will find, information related to proper documentation requirements including a physician letter, documentation checklists, FAQs, and a presentation used during Web-based workshops.

Suppliers can also review a specific policy Documentation Checklist for Lower Limb Prosthesis on the Noridian website.

Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations.

Information about probe/error validation reviews may be found in CMS Publication 100-8, Program Integrity Manual This link will take you to an external website. (PIM), Chapter 3.

Policy Education

Documentation was not received in response to the Additional Documentation Request (ADR) letter.

Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the National Supplier Clearinghouse (NSC). The supplier standards can be found in 424 CFR Section 424.57(c).

Please remember, the documentation must be submitted within 45 days from the date on the ADR letter. Failure to provide the requested documentation within 45 days may result in a partial or complete denial of the claim. Submission information can be found on the ADR page of Noridian's website.

Documentation does not support medical need for replacement item.

Medicare payment may be made for the replacement of prosthetic devices which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if an ordering physician determines that the replacement device, or replacement part of such a device, is reasonable and necessary. Claims involving the replacement of a prosthesis or major component (foot, ankle, knee, socket) must be supported by a new physician's order and documentation supporting the reason for the replacement. The reason for replacement must be documented by the treating physician, either on the order or in the medical record, and must fall under one of the following:

  • A change in the physiological condition of the patient resulting in the need for a replacement. Examples include but are not limited to, changes in beneficiary weight, changes in the residual limb, beneficiary functional need changes; or,
  • 2. An irreparable change in the condition of the device, or in a part of the device resulting in the need for a replacement; or,
  • 3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.

Documentation does not support the functional level billed.

A determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:

  • The beneficiary's past history (including prior prosthetic use if applicable); and
  • The beneficiary's current condition including the status of the residual limb and the nature of other medical problems; and
  • The beneficiary's desire to ambulate.

The records must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.

Documentation does not support basic coverage criteria.

A lower limb prosthesis is covered when the beneficiary:

  • Will reach or maintain a defined functional state within a reasonable period of time; and
  • Is motivated to ambulate.

Detailed Written Order (DWO) is incomplete or missing elements.

The supplier for all durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. The treating physician must sign and date the detailed written order.

DISPENSING ORDERS (PIM 5.2.2)

Equipment and supplies may be delivered upon receipt of a dispensing order except for those items that require a written order prior to delivery. A dispensing order may be verbal or written. The supplier must keep a record of the dispensing order on file. It must contain:

  • Description of the item
  • Beneficiary's name
  • Prescribing Physician's name
  • Date of the order and the start date, if the start date is different from the date of the order
  • Physician signature (if a written order) or supplier signature (if verbal order)

For the "Date of the order" described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders).
Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.

The dispensing order must be available upon request.

For items that are provided based on a dispensing order, the supplier must obtain a detailed written order before submitting a claim.

DETAILED WRITTEN ORDERS (PIM 5.2.3)

A detailed written order (DWO) is required before billing. Someone other than the ordering physician may produce the DWO. However, the ordering physician must review the content and sign and date the document. It must contain:

  • Beneficiary's name
  • Physician's name
  • Date of the order and the start date, if start date is different from the date of the order
  • Detailed description of the item(s) (see below for specific requirements for selected items)
  • Physician signature and signature date

For items provided on a periodic basis, including drugs, the written order must include:

  • Item(s) to be dispensed
  • Dosage or concentration, if applicable
  • Route of Administration, if applicable
  • Frequency of use/testing frequency, for test strips and lancets
  • Duration of infusion, if applicable
  • Quantity to be dispensed
  • Number of refills

For the "Date of the order" described above, use the date the supplier is contacted by the physician (for verbal orders) or the date entered by the physician (for written dispensing orders).
Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state "PRN" or "as needed" utilization estimates for replacement frequency, use, or consumption are not acceptable. (PIM 5.9)
The detailed description in the written order may be either a narrative description or a brand name/model number.

Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 3.3.2.4.

The DWO must be available upon request.

Last Updated Apr 05, 2016