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Prosthetics

Coverage

Documentation

Prior Authorization Timelines

Policy Initial Review
Decision Timeframe
Expedited Review
Decision Timeframe
PAR Decision Valid
LLP 10 business days 2 business days 120 days

 

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Topic Details

Articulating Digit(s) and Prosthetic Hands - Correct Coding - Revised

Joint DME MAC Publication for Articulating Digit(s) and Prosthetic Hands - Correct Coding - Revised

External Breast Prostheses Bra/Camisole

  • LCD does not specify quantities of bras or camisoles that are covered. A physician determines what is reasonable and necessary on a case-by-case basis. Medical records should reflect and support what is ordered and dispensed to a beneficiary. Bras are a non-consumable item that fall under refill requirements and a supplier may only dispense a three-month quantity at one time
  • Bra - Mastectomy Bras, HCPCS L8000, L8001 and L8002 cannot be billed as an upgrade, even if bra is more expensive and may not be upgraded as the code definitions are not limited to a specific type of fabric, style, or cost, but rather, encompasses all fabrics, styles, and costs. The only HCPCS codes that can be billed as an upgrade in LCD are HCPCS L8031 and L8035. CMS Internet Only Manual (IOM), Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 120 describes an upgrade as "an item with features that go beyond what is medically necessary. An upgrade may include an excess component. An excess component may be an item, feature, or service, which is in addition to, or is more extensive and/or more expensive than item that is reasonable and necessary under Medicare's coverage requirements." A difference in price alone is not justification for an upgrade
  • Camisole - LCD indicates HCPCS L8015 is covered when a beneficiary uses this garment during postoperative period prior to being fitted with a permanent breast prosthesis, or wears garment as an alternative to mastectomy bras and breast prosthesis. A camisole may be covered for years after surgery as an alternative to a prosthesis and bra

Resources

Canceled Orders for Customized Items (salvage value)
  • Suppliers may be reimbursed for the labor and parts involved in customization when an order is canceled, or the beneficiary expires prior to delivery. When billing, include a claim narrative explaining reason for cancellation (e.g., death, canceled, etc.) in Item 19 of CMS-1500 claim form or NTE segment of loop 2400 on an electronic claim. Date of service (DOS) on claim must be date order was canceled or date of beneficiary death. Please refer to the CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15, Section 20.3 for more information.
Consolidated Billing
  • Under the consolidated billing requirement, a skilled nursing facility (SNF) must submit all Medicare claims for services that its residents receive, except for specifically excluded services. You can find a list of excluded services on the bottom of the Noridian Consolidated Billing webpage. Select 2021 or 2022 SNF Excluded Codes. If a code appears on the list, it can be billed directly to the DME MAC by the supplier. Suppliers can also find excluded services using our Consolidated Billing tool on our website. Some lower limb prosthetics appear on this list.
DMEPOS Payments While Inpatient
External Breast Items Billed Unassigned
  • Since upgrades are not allowed for bras or camisoles, a non-participating supplier can bill claims for bras and camisoles as unassigned. Beneficiary will be required to pay for bras when they are dispensed (at full price) and will receive reimbursement directly from Medicare for allowed amount; however, participating suppliers do not have this option, they must accept Medicare's allowed amount as payment in full
Item Provided Prior to Surgery
  • Do not provide items to a beneficiary before medical necessity has occurred. Per CMS IOM, Publication 100-02, Medicare Benefit Policy Manual, Chapter 15, Section 120. "Medicare does not cover a prosthetic device dispensed to a patient prior to the time at which the patient undergoes the procedure that makes necessary the use of the device... Moreover, the need for the device cannot be clearly established until the procedure that makes its use possible is successfully performed." Delivery of DME may be within two days of anticipated discharge from a hospital or Skilled Nursing Facility (SNF) for fitting/training purposes, when discharge is to home. Date of service must be discharge date
Prior Authorization
  • PA is required for six LLP HCPCS codes: L5856, L5857, L5858, L5973, L5980, L5987
External Breast and Lower Limb Prosthetic Refills
  • Items such as bras and socks or liners are considered non-consumable items and therefore may be treated as a refill item. If Standard Written Order (SWO) identifies these items with quantity, they may be dispensed as needed without obtaining a new order. For more information, see the Standard Documentation Requirements article for documentation requirements for refills of non-consumable supplies

Repairs

  • Labor and Minor Parts HCPCS Codes
    • L7510 - Repair of prosthetic device, repair or replace minor parts
      • Code L7510 is used to bill for any "minor" materials (e.g., those without specific HCPCS codes) used to achieve the adjustment and/or repair.
      • A claim for code L7510 must include a description of each item that is billed. This information should be entered in the narrative field on the claim.
    • L7520 - Repair prosthetic device, labor component, per 15 minutes
      • Code L7520 is used to bill for labor associated with adjustments and repairs that either do not involve replacement parts or that involve replacement parts billed with code L7510.
      • A claim for code L7520 must include an explanation of what is being repaired. This information should be entered in the narrative field on the claim.
        • Code L7520 must not be billed for labor time involved in the replacement of parts that are billed with a specific HCPCS code. Labor is included in the allowance for those codes.
    • Documentation must exist in the supplier's records indicating the specific adjustment and/or repair performed, and the time involved. The time reported for L7520 must only be for actual repair time. Time performing the following services (not all-inclusive) must not be billed using code L7520:
      • Evaluation to determine the need for a repair or adjustment or follow-up assessment
      • Evaluation of problems regarding the fit or function of the prosthesis
      • General beneficiary education or gait instruction
      • Programming of electronic componentry
    • Repairs to a prosthesis are covered when necessary to make the prosthesis functional. If the expense for repairs exceeds the estimated expense of purchasing another entire prosthesis, no payments can be made for the amount of the excess.
  • Maintenance per the manufacturer's recommendations or the construction of the prosthesis that must be performed by the prosthetist is covered as a repair.
Replacement
  • There are special rules for the replacement of artificial arms, lower limbs, and eyes.
RT/LT Modifiers
  • Suppliers must bill each item on two separate claim lines using the RT and LT modifiers and 1 UOS on each claim line. Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or with the RTLT on a single claim line, will be rejected as incorrect coding.

 

Reviews/Audits

  • Medical Review - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review

 

Last Updated Wed, 11 Jan 2023 13:28:05 +0000

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.

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