Prosthetics - JD DME

View the joint DME MAC publication Articulating Digit(s) and Prosthetic Hands - Correct Coding - Revised for billing information.

All LLP HCPCS codes must be submitted with either RT or LT modifier along with either the KX, GA, GZ, or GY modifier.

HCPCS codes L5973, L5976, L5979, L5980, L5981, L5987, L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5856, L5857, and L5858 can now be allowed with the K2, K3, or K4 modifier. Previously, these HCPCS codes were only allowed with a K3 or K4 modifier.

HCPCS codes L5615 and L5841 will now require either a K0, K1, K2, K3, or K4 modifier.

Suppliers may be reimbursed for the labor and parts involved in customization when an order is canceled, or the beneficiary expires prior to delivery. Follow the guidelines for Canceled Orders for Customized Items to facilitate the reimbursement process. Please refer to the CMS Internet Only Manual (IOM), Publication 100-02, Chapter 15, Section 20.3 for more information.

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 the applicable year's SNF Excluded Codes file. 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.

Refer to the Medicare DMEPOS Payments While Inpatient MLN Fact Sheet for information on inpatient payments, deliveries before inpatient discharge, and interruptions in period of continuous use.

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 SNF for fitting/training purposes, when discharge is to home. The date of service must be the discharge date.

Items such as bras and socks or liners are considered refillable items. If a 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.

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.

There are special rules for the replacement of artificial arms, lower limbs, and eyes.