Prosthetics - JD DME

• Coverage and Documentation
• External Breast Prostheses
• Eye Prostheses
• Facial Prostheses
• Lower Limb Prostheses
• Tips

Coverage and Documentation

• Standard Documentation Requirements for All Claims Submitted to DME MACs
• Clinician Letter - Documentation of Artificial Limbs and Braces [PDF]

External Breast Prostheses

• Local Coverage Determination (LCD)
• Policy Article
• Clinician Checklist [PDF]
• Documentation Checklist [PDF]

The 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.

Bra - Mastectomy bras, HCPCS L8000, L8001, and L8002 cannot be billed as an upgrade, even if the 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, encompass all fabrics, styles, and costs. The only HCPCS codes that can be billed as an upgrade in the 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 the item that is reasonable and necessary under Medicare's coverage requirements." A difference in price alone is not justification for an upgrade. Bras fall under the refill requirements. A supplier may only dispense a three-month quantity at one time.

Camisole - The LCD indicates HCPCS L8015 is covered when a beneficiary uses this garment during a postoperative period prior to being fitted with a permanent breast prosthesis or wears the garment as an alternative to a mastectomy bra and breast prosthesis. A camisole may be covered for years after surgery as an alternative to a prosthesis and bra.

Upgrades - Since upgrades are not allowed for bras or camisoles, a non-participating supplier can bill claims for bras and camisoles as unassigned. The beneficiary will be required to pay for bras when they are dispensed (at full price) and will receive reimbursement directly from Medicare for the allowed amount; however, participating suppliers do not have this option, they must accept Medicare's allowed amount as payment in full.

Eye Prostheses

• Local Coverage Determination (LCD)
• Policy Article

Facial Prostheses

• Local Coverage Determination (LCD)
• Policy Article

Lower Limb Prostheses

• Local Coverage Determination (LCD)
• Policy Article
• Clinician Checklist - Lower Limb Prosthesis - Initial [PDF]
• Clinician Checklist - Lower Limb Prosthesis - Replacement [PDF]
• Documentation Checklist [PDF]

Prior Authorization

Prior authorization is required for the following HCPCS codes: L5856, L5857, L5858, L5973, L5980, and L5987.

Tips

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

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

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 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.

DMEPOS Payments While Inpatient

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.

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

Refills (External Breast and Lower Limb Prostheses)

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

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.

Replacement

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