Lower Limb Prostheses - Policy Article

**NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES**  
  
For any item to be covered by Medicare, it must 1) be eligible for a defined
Medicare benefit category, 2) be reasonable and necessary for the diagnosis or
treatment of illness or injury or to improve the functioning of a malformed
body member, and 3) meet all other applicable Medicare statutory and
regulatory requirements. Information provided in this policy article relates
to determinations other than those based on Social Security Act 1862(a)(1)(A)
provisions (i.e. "reasonable and necessary").  
  
Lower limb prostheses are covered under the Medicare Artificial Legs, Arms and
Eyes benefit (Social Security Act 1861(s)(9)). In order for a beneficiary's
lower limb prosthesis to be eligible for reimbursement, the reasonable and
necessary (R&N) requirements set out in the related Local Coverage
Determination must be met. In addition to meeting the benefit policy, there
are specific statutory payment policy requirements, discussed below, that also
must be met.  
  
GENERAL:  
  
A repair is a restoration of the prosthesis to correct problems due to wear or
damage.  
  
An adjustment is any modification to the prosthesis due to a change in the
beneficiary's condition or to improve the function of the prosthesis.  
  
The following items are included in the reimbursement for a prosthesis and,
therefore, are not separately billable to Medicare under the prosthetic
benefit:

  * Evaluation of the residual limb and gait

  * Fitting of the prosthesis

  * Cost of base component parts and labor contained in HCPCS base codes

  * Repairs due to normal wear or tear within 90 days of delivery

  * Adjustments of the prosthesis or the prosthetic component made when fitting the prosthesis or component and for 90 days from the date of delivery when the adjustments are not necessitated by changes in the residual limb or the beneficiary's functional abilities.

Payment for Prostheses Provided During a Medicare Part A Covered Hospital Stay

Payment by Medicare Part A for a prosthesis provided to a beneficiary for use
during a Medicare Part A covered hospital stay is eligible for inclusion in
the payment for the hospital stay if the following criteria (1 and 2) are met:

  1. The prosthesis is provided to a beneficiary during the inpatient hospital stay; and,

  2. The beneficiary uses the prosthesis for reasonable and necessary inpatient treatment or rehabilitation.

In this situation, a claim must not be submitted to the DME MAC.  
  
Payment by the DME MAC for a prosthesis delivered to a beneficiary, not for
use during a Medicare Part A covered hospital stay, is eligible for DME MAC
coverage if the following criteria (1 - 3) are met:

  1. The prosthesis is reasonable and necessary for a beneficiary after discharge from a hospital; and,

  2. The prosthesis is delivered to the beneficiary no more than two days prior to discharge to home; and,

  3. The prosthesis is not used for inpatient treatment or rehabilitation.

Payment for Prostheses Provided During a Medicare Part A Covered Skilled
Nursing Facility (SNF) Stay

Payment by Medicare Part A for a prosthesis provided to a beneficiary,
described by codes L5000, L5010, L5020, L5400, L5410, L5420, L5430, L5450,
L5460, L5987, L8400, L8410, L8417, L8420, L8430, L8440, L8460, L8470, and
L8480, for use during a Medicare Part A covered SNF stay is eligible for
inclusion in the payment for the SNF stay if the following criteria (1 and 2)
are met:

  1. The prosthesis is provided to a beneficiary during the SNF stay; and,

  2. The beneficiary uses the prosthesis for reasonable and necessary treatment or rehabilitation.

In this situation, a claim must not be submitted to the DME MAC.  
  
Claims (other than for the above HCPCS codes) for a lower limb prosthesis
provided to a beneficiary during a Medicare Part A covered SNF stay (see
below), and claims for any lower limb prosthesis provided to a beneficiary
during a non-covered Medicare Part A SNF stay, are to be submitted to the DME
MAC.

Payment by the DME MAC for a prosthesis delivered to a beneficiary during a
Part A covered SNF stay is eligible for DME MAC coverage if:

  1. The prosthesis is reasonable and necessary for a beneficiary's use during the Medicare Part A covered SNF stay; and,

  2. The prosthetic components are classified as major category III codes under the SNFs consolidated billing.

  
ADJUSTMENTS, REPAIRS, AND COMPONENT REPLACEMENT:  
  
Routine periodic servicing, such as testing, cleaning, and checking of the
prosthesis is noncovered. Adjustments to a prosthesis required by wear or by a
change in the beneficiary's condition are covered under the initial treating
practitioner's order for the prosthesis for the life of the prosthesis.  
  
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 which may be necessitated by manufacturer's
recommendations or the construction of the prosthesis and must be performed by
the prosthetist is covered as a repair.  
  
Replacement of a prosthesis or prosthetic component is covered if the treating
practitioner orders a replacement device or part because of any of the
following:

  1. A change in the physiological condition of the beneficiary; or

  2. Irreparable wear of the device or a part of the device; or

  3. The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or of the part being replaced.

Replacement of a prosthesis or prosthetic components required because of loss
or irreparable damage may be reimbursed without a practitioner's order when it
is determined that the prosthesis as originally ordered still fills the
beneficiary's medical needs.  
  
MISCELLANEOUS:  
  
A prosthetic donning sleeve (L7600) will be denied as noncovered.  
  

**REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed.
Reg Vol 217)**

Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a
Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the
DME MACs provide a list of the specified codes, which is periodically updated.
The required Face-to-Face Encounter and Written Order Prior to Delivery List
is available [here](https://www.cms.gov/Research-Statistics-Data-and-
Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-
Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment).

Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol
217) that do not meet the face-to-face encounter and WOPD requirements
specified in the LCD-related Standard Documentation Requirements Article
(A55426) will be denied as not reasonable and necessary.

If a supplier delivers an item prior to receipt of a WOPD, it will be denied
as not reasonable and necessary. If the WOPD is not obtained prior to
delivery, payment will not be made for that item even if a WOPD is
subsequently obtained by the supplier. If a similar item is subsequently
provided by an unrelated supplier who has obtained a WOPD, it will be eligible
for coverage.  
  

**POLICY SPECIFIC DOCUMENTATION REQUIREMENTS**  
  
In addition to policy specific documentation requirements, there are general
documentation requirements that are applicable to all DMEPOS policies. These
general requirements are located in the DOCUMENTATION REQUIREMENTS section of
the LCD.  
  
Refer to the LCD-related Standard Documentation Requirements article, located
at the bottom of this Policy Article under the Related Local Coverage
Documents section for additional information regarding GENERAL DOCUMENTATION
REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed
below.  
  
When submitting a prosthetic claim, the billed code for knee, foot, ankle and
hip (HCPCS codes L5610, L5611, L5613, L5614, L5616, L5710, L5711, L5712,
L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780, L5810, L5811, L5812,
L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, L5848, L5856,
L5857, L5858, L5859, L5930, L5961, L5970, L5971, L5972, L5973, L5974, L5975,
L5976, L5978, L5979, L5980, L5981, L5982, L5984, L5985, L5986, L5987)
components must be submitted with modifiers K0 - K4, indicating the expected
beneficiary functional level. This expectation of functional ability
information must be clearly documented and retained in the prosthetist's
records. The simple entry of a K modifier in those records is not sufficient.
There must be information about the beneficiary's history and current
condition which supports the designation of the functional level by the
prosthetist.  
  
For L5859, the medical records should describe the nature and extent of the
comorbidity of the spine or the sound limb which is what is limiting this
beneficiary to a household ambulator, and clearly document how this feature
will enable the beneficiary to function as a community ambulator.  
  
Refer to the Supplier Manual for more information on documentation
requirements.  
  
REPAIR/REPLACEMENT (BPM Ch 15, 120)  
  
Adjustments and repairs of prostheses and prosthetic components are covered
under the original order for the prosthetic device.  
  
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 a treating
practitioner 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 treating practitioner's order and documentation supporting
the reason for the replacement. The reason for replacement must be documented
by the treating practitioner, either on the order or in the medical record,
and must fall under one of the following:

  1. 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.

The prosthetist must retain documentation of the prosthesis or prosthetic
component replaced, the reason for replacement, and a description of the labor
involved irrespective of the time since the prosthesis was provided to the
beneficiary. This information must be available upon request. It is recognized
that there are situations where the reason for replacement includes but is not
limited to: changes in the residual limb; functional need changes; or
irreparable damage or wear/tear due to excessive beneficiary weight or
prosthetic demands of very active amputees.

  
**CONTINUED MEDICAL NEED**  
  
For all DMEPOS items, the initial justification for medical need is
established at the time the item(s) is first ordered, therefore, beneficiary
medical records demonstrating that the item is reasonable and necessary are
created just prior to, or at the time of, the creation of the initial
prescription. Once initial medical need is established, unless continued
coverage requirements are specified in the LCD, ongoing need for the lower
limb prosthesis is assumed to be met. There is no requirement for further
documentation of continued medical need as long as the beneficiary continues
to meet the Artificial Legs, Arms and Eyes benefit.

  
**MODIFIERS**

LT and RT MODIFIERS:

The right (RT) and left (LT) modifiers must be used with prosthesis codes
(refer to the CODING GUIDELINES section for additional information).

  
**CODING GUIDELINES**  
  
REPAIR AND LABOR CODING

Code L7510 is used to bill for any "minor" materials (i.e., those without
specific HCPCS codes) used to achieve the adjustment and/or repair.  
  
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. 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.  
  
One unit of service of code L7520 represents 15 minutes of labor time.
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

  
SUSPENSION

Code L5671 includes both the part of the suspension locking mechanism that is
integrated into the prosthesis socket and the pin(s), lanyard, or other
component which is attached to the socket insert. L5671 does not include the
socket insert itself. The socket inserts used in conjunction with a suspension
locking mechanism are billed with codes L5673, L5679, L5681, or L5683, as
appropriate. These codes include socket inserts with or without a distal
umbrella adapter for attaching the pin or lanyard of the locking mechanism.  
  
Codes L5681 and L5683 are for use only with the initial issue of a custom
fabricated socket insert. Additional inserts (either custom fabricated or
prefabricated) provided at the time of initial issue or replacement socket
inserts are coded L5673 and L5679, whichever is applicable.  
  
Codes L5647 and L5652 describe a modification to a prosthetic socket that
incorporates a suction valve in the design. The items described by these codes
are not components of a suspension locking mechanism (L5671).

L5781 describes a complete device that is an addition to a lower limb
prosthesis. The primary function of the vacuum pump is to suspend the
prosthetic limb. Additionally, products coded L5781 provide residual limb
volume management and moisture evacuation. The pump mechanism evacuates air
and accumulated moisture between the limb and socket walls. The pump mechanism
can be actuated by either external power and/or mechanical system(s).

L5782 describes a complete device that is an addition to a lower limb
prosthesis. The primary function of the vacuum pump is to suspend the
prosthetic limb. It also provides residual limb volume management and moisture
evacuation. The pump mechanism evacuates air and accumulated moisture between
the limb and socket walls. The pump mechanism can be actuated by either
external power and/or mechanical system(s). Products described by this code
would have components built to withstand higher prosthetic limb forces than
L5781.

Code L7700 (GASKET OR SEAL, FOR USE WITH PROSTHETIC SOCKET INSERT, ANY TYPE,
EACH) describes a stand-alone (i.e., not integrated into or a part of a
prosthetic socket insert) sealing ring that is added to a socket insert to
assist in providing or maintaining negative pressure for socket suspension.
The ring creates a seal against the outer surface of the insert and against
the inner wall of the socket. L7700 is not intended for use with mechanical
socket suspensions such as a pin-lock system. It may be made of any suitable
material. L7700 may be used with upper or lower extremity sockets. Unit of
service (UOS) is 1 (one) item. This code is not to be used to bill for
gaskets, seals, or other sealing materials that are included as part of an
insert. Integrated seals are included in the code for the insert. Separate
billing of integrated gaskets or seals as L7700 is unbundling.

  
PROSTHETIC SYSTEMS

Exoskeletal prosthetic lower limb codes L5200, L5250, L5270, L5280 include a
molded prosthetic socket, and exoskeletal single axis knee-shin system, and a
SACH foot.

L5150 and L5160 includes a knee disarticulation molded prosthetic socket,
external knee joints, and a SACH foot.

Endoskeletal prosthetic lower limb codes L5312, L5321, L5331, L5341 include
molded prosthetic socket, an endoskeletal single axis knee-shin system and a
SACH foot.

L5100, L5105, L5301 includes a below knee molded prosthetic socket, and a SACH
foot.

  
PROSTHETIC CONNECTORS

L5991 describes a complete endoskeletal product that is used as an
osseointegrated external limb prosthetic connection device. The product
provides a standard connection between an osseointergrated implantable limb
component and endoskeletal prosthetic components. L5991 describes a complete
device, and the use of additional codes would be considered incorrect coding
(unbundling). The predicate product is the Axor II osseointegrated external
prosthetic connection device manufactured by Integrum, S.E.

  
SOCKETS

Codes L5940, L5950, and L5960 for ultra-light materials may only be used when
materials such as carbon fiber, fiberglass, Kevlar, or other advanced
composite lamination materials are used in the fabrication of a socket for an
endoskeletal prosthesis. They are not used for ultralight materials used in
other components of a prosthesis - e.g., knee/shin system, pylon, ankle, foot.
For codes L5940, L5950, and L5960, the unit of service is per limb.

L5301, L5540, L5321, L5590 should not be used when billing a replacement
socket for an existing prosthesis. The use of L5301, L5540, L5321, L5590 with
a replacement socket is incorrect coding (unbundling). Code L5999 (LOWER
EXTREMITY PROSTHESIS, NOT OTHERWISE SPECIFIED) must not be used to bill for
any features or functions included in the socket or addition codes. Use of
L5999 is incorrect coding (unbundling).

Infinite Socket (LIM Innovations) is an open-socket design that has distinct
below knee and above knee products. These sockets are custom-fabricated from a
model of the patient's residual limb and utilize struts that extend from a
base to an adjustable brim enclosing an inner shell to form the primary
structure of the socket. The LIM Innovations socket is functionally equivalent
to design features of current HCPCS codes. The correct combination of HCPCS
codes for the Infinite Socket TT-S (below-knee socket) are L5301 or L5700 with
the addition of L5629, L5637, and L5940. The correct combination of HCPCS
codes for the Infinite Socket T/F (above-knee socket) are L5321 or L5701 with
the addition of L5631, L5649, and L5950.

  
PROTECTIVE COVERS

Lower limb prosthetic covers (L5704, L5705, L5706, and L5707) are complete
products and afford shape, protection and waterproofing for normal daily usage
of the prosthesis. They offer sufficient protection and weatherproofing for
beneficiaries who require lower limb prosthetics.

Protective outer surface covering systems (L5962, L5964, and L5966) are
specialized covers intended to be worn over an existing prosthesis. They are
used by a beneficiary who has special needs for protection against unusually
harsh environmental situations where it is necessary to protect the lower limb
prosthesis beyond the level of protection that is afforded by L5704, L5705,
L5706, and L5707. They are not for cosmetic or convenience reasons, or for
everyday usage in a typical environment. Protective outer surface coverings
are different from the covering that is already reimbursed as part of L5704,
L5705, L5706, and L5707.

  
FOOT COVERS

Foot covers are included in the codes for a prosthetic foot component and are
not separately payable.

  
KNEES

With the exception of items described by specific HCPCS codes, there should be
no separate billing and there is no separate payment for a component or
feature of a microprocessor controlled knee, including but not limited to real
time gait analysis, continuous gait assessment, or electronically controlled
static stance regulator.

Addition codes for exoskeletal knee-shin systems (L5614, L5710, L5711, L5712,
L5714, L5716, L5718, L5722, L5724, L5726, L5728, L5780) are considered an
upgrade to the knee-shin system. The beneficiary may qualify for an upgraded
knee-shin system depending on their assigned K-level modifier (K0-K4), as
referenced in the LCD. These HCPCS codes can fully describe a complete
prosthetic knee-shin system commonly referred to as a "base knee code". A
single addition code can fully describe a complete knee-shin system and thus
the use of two codes from the list would be considered incorrect coding
(unbundling).

Addition codes for endoskeletal knee-shin systems (L5610, L5611, L5613, L5616,
L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830,
L5840) are considered an upgrade to the knee-shin system. The beneficiary may
qualify for an upgraded knee-shin system based on their assigned K-Level
modifier (K0-K4), as referenced in the LCD. These HCPCS codes can fully
describe a complete prosthetic knee-shin system commonly referred to as a
"base knee code". A single addition code can fully describe a complete knee-
shin system and thus the use of two codes (L5610, L5611, L5613, L5616, L5810,
L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840)
would be considered incorrect coding (unbundling).

L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional
features and/or functions that do not describe a complete endoskeletal knee-
shin system and must be used in combination with an L-code for a knee-shin
system (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818,
L5822, L5824, L5826, L5828, L5830, L5840). The use of additional feature
L-codes may also depend on the assigned K-Level modifier (K0-K4), as
referenced in the LCD.

L5845 describes an endoskeletal product that is used as an addition to L-code
Knee-Shin Systems for lower limb prosthesis construction. The product provides
shock absorption during the initial stance phase of gait. It is designed to
simulate the eccentric contraction of the quadriceps to reduce trauma on the
residual limb. The predicate product is the Stance Flexion Feature, Adjustable
manufactured by Endolite North America.

L5848 refers to a feature of an endoskeletal knee component which is
incorporated into the entire knee-shin system. The Hydraulic Stance Extension
Dampening Feature restricts the prosthetic knee joint's extension moment
during the transition of mid to late stance phase of gait. The predicate
products are the Otto Bock 3R60, 3C98 and 3C88 Hydraulic Knees.

L5856 refers to a feature of an endoskeletal knee component which is
incorporated into the entire knee-shin system. The microprocessor componentry
with sensors, any type, provide automated adjustment for controlling the swing
and stance phase of gait. This feature would be discernable from schematic
drawings and user manual documentation. The documentation would provide
details for all of the adjustments for the dynamic properties of this sub-
system within the knee component. Adjustments could factor user
characteristics such as the activity level, body weight, or gait preferences,
among others. This adjustment feature is energized by an on-board rechargeable
battery source. The code would include any external components needed to
access the microprocessor for modification of the settings.

L5857 refers to a feature of an endoskeletal knee component which is
incorporated into the entire knee-shin system. The microprocessor componentry
with sensors, any type, provide automated adjustment for controlling the swing
phase of gait. The documentation would provide details for all of the
adjustments for the dynamic properties of this sub-system within the knee
component. Adjustments could factor user characteristics such as the activity
level, body weight, or gait preferences, among others. This adjustment feature
is energized by an on-board rechargeable battery source. The code would
include any external components needed to access the microprocessor for
modification of the settings.

L5858 refers to a feature of an endoskeletal knee component which is
incorporated into the entire knee-shin system. The microprocessor componentry
with sensors, any type, provide automated adjustment for controlling the
stance phase of gait. The documentation would provide details for all of the
adjustments for the dynamic properties of this sub-system within the knee
component. Adjustments could factor user characteristics such as the activity
level, body weight, or gait preferences, among others. This adjustment feature
is energized by an on-board rechargeable battery source. The code would
include any external components needed to access the microprocessor for
modification of the settings.

L5926 describes an endoskeletal above the knee positioning device that allows
360 degrees of rotation and locks the endoskeletal prosthetic knee and foot
system in a neutral position for ambulation. The predicate product is the
Ottobock 4R57 Rotation Adapter.

  
ANKLE AND LOWER EXTREMITY MOTION UNITS

Codes L5968, L5982, L5984, L5985, L5986 and L5988 describe separate products
which provide either a single motion or a combination of motions generally
attributed to functional movement of the lower limb during ambulation. The use
of these codes can be used to fully describe additional features or functions
not found in the prosthetic foot system (L5969, L5970, L5971, L5972, L5973,
L5974, L5975, L5976, L5978, L5979 L5980, L5981 and L5987).

L5968 describes a product that is used as an addition to L-code foot systems
for lower limb prosthesis construction. The product provides multiaxial motion
in the coronal and sagittal plane from articulating components. At transition
of stance phase to swing phase, the product will increase the ankle's
dorsiflexion angle and maintain it throughout swing phase. The product
provides an accommodation of changing heel heights without the user's input.
The predicate product is the Rincoe R-Hab Ankle manufactured by R.G. Rincoe &
Associates, Inc.

L5982 describes an exoskeletal device that allows adjustable amount of
vertical twisting motion between the foot and pelvis during ambulation. Motion
of this product is separate from any similar incidental prosthetic foot/ankle
motions.

L5984 describes an endoskeletal device that allows an adjustable, or non-
adjustable, amount of vertical twisting motion between the foot and pelvis
during ambulation. Motion of this product is separate from any similar
incidental prosthetic foot/ankle motions.

L5985 describes an endoskeletal pylon device that provides simulated
multiaxial ankle motion through a dynamic vertical shank separate from any
similar incidental prosthetic foot motions. The predicate product is The
Seattle Ankle manufactured by Seattle Medical Systems Group.

L5986 describes a product that is used as an addition to L-code foot systems
for lower limb prosthesis construction. The product provides multiaxial motion
in all three planes of motion, sagittal, coronal, and transverse. This code
does not describe the multiaxial motion achieved from the inherent flexibility
of the prosthetic keel or a split keel/heel prosthetic foot design. The
predicate product is a device that was manufactured by Medical Center
Prosthetic, which is represented in the coding narrative by "MCP."

Use of L5968, L5982, L5984 or L5986 is based on the beneficiary's K-level
modifier (K0-K4), as referenced in the LCD.

L5988 describes an endoskeletal pylon device that allows vertical shock
reduction between the foot and pelvis during ambulation. The vertical shock
reducing pylon feature of L5988 is a separate function from other products
which use a piston/telescoping mechanism such as products described by L5781
or L5782. The predicate product is the Total Shock that was manufactured by
Century XXII International, Inc.

  
FEET

Addition codes for lower extremity prostheses, L5970, L5971, L5972, L5974,
L5975, L5976, L5978, L5979, L5980, L5981, L5987 are considered an upgrade to
the SACH foot. The beneficiary may qualify for an upgraded prosthetic foot
based on their assigned K-level modifier (K0-K4) as referenced in the LCD. A
single addition code (L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979,
L5980, L5981, L5987) can fully describe a complete foot and thus the use of
more than one code would be considered incorrect coding (unbundling).

L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or
functions that do not describe a complete prosthetic foot and may be used in
combination with L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979,
L5980, L5981, and L5987. The use of additional feature L-codes may also depend
on the assigned K-Level modifier (K0-K4) as referenced in the LCD.

L5980 describes a product that can be used for either endoskeletal or
exoskeletal lower limb construction. The Flex Foot has an energy storing
J-shaped keel design. Heel component is attached onto the J-shaped keel
section. The Flex Foot System's J-shaped keel design extends proximally as a
monolithic composite shank. Shank height is determined and modified by
supplier to utilize the dynamics of the composite shank. L5980 includes foot
cover.

L5981 describes a product that can be used for either endoskeletal or
exoskeletal lower limb construction. The Flex Walk has an energy storing
J-shaped keel design. Heel component is attached to the J-shaped keel section.
The Flex Walk J-shaped keel design proximally terminates at a nonadjustable
fixed height determined and modified by the prosthetic foot manufacturer.
L5981 includes foot cover.

L5987 describes a product that can be used for either endoskeletal or
exoskeletal lower limb construction. All components are integrated as a single
product, i.e. not an assembly of separate products or components. The product
has an energy storing J-shaped keel design. Heel component is attached onto
the J-shaped keel section. Vertical loading pylon allows controlled motion for
shock absorption. This code does not describe vertical loading or shock
absorption achieved from the inherent flexibility of the J-shaped keel
section. L5987 includes foot cover.

  
PARTIAL FOOT AND TOE FILLER INSERTS

Codes L5000, L5010, and L5020 describe products that are necessary for
standing balance and toe off support in beneficiaries who are missing the
forefoot or digits including the hallux (great toe) and who require the
rigidity and support offered by these products, in order to achieve or
maintain an effective gait.

L5000 describes a shoe insert with a rigid longitudinal arch support that also
incorporates material accommodating the void left by the missing digit(s) or
forefoot. Additional soft material is added where contact is made with the
residual limb or toes. These inserts are designed to provide standing balance
and toe off support for improved gait. L5000 is inclusive of variations in
materials or combinations such as differing stiffnesses or Shore value.

L5010 describes a partial foot device including a molded socket for the
residual limb with a proximal height terminating at the ankle or extending
proximally as needed to achieve appropriate support and function. L5010 is
inclusive of a rigid longitudinal arch support that also incorporates material
accommodating the void left by the missing digit(s) or forefoot. Additional
soft material is added where contact is made with the residual limb or toes.
L5010 devices are designed to provide standing balance and toe off support for
improved gait. All closures are included, any type. L5010 is inclusive of
variations in materials or combinations such as differing stiffnesses or Shore
value.

L5020 describes a partial foot device including a molded socket for the
residual limb with a proximal height terminating at or near the tibial
tubercle to achieve appropriate support and function. L5020 is inclusive of a
rigid longitudinal arch support that also incorporates material accommodating
the void left by the missing digit(s) or forefoot. Additional soft material is
added where contact is made with the residual limb or toes. L5020 devices are
designed to provide standing balance and toe off support for improved gait.
All closures are included, any type. L5020 is inclusive of variations in
materials or combinations such as differing stiffnesses or Shore value.

  
MICROPROCESSOR ANKLE FOOT SYSTEMS

With the exception of items described by specific HCPCS codes, there should be
no separate billing and there is no separate payment for a component or
feature of a microprocessor controlled foot, including but not limited to real
time gait analysis, continuous gait assessment, or electronically controlled
static stance regulator.

L5973 describes an endoskeletal device with integrated energy storage and
release foot and microprocessor ankle system. The integrated microprocessor is
programmable along with sensors to optimize plantar and dorsiflexion angles
for stance and swing phase. L5973 includes foot cover, power source(s) and
charger.

A microprocessor ankle-foot system with power assist (BiOM Ankle-Foot System
by iWalk, Inc) is coded as the combination of L5969 (ADDITION, ENDOSKELETAL
ANKLE-FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S)) and
L5973 (ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE,
DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE).

  
The right (RT) and left (LT) modifiers must be used with prosthesis codes.
Effective for claims with dates of service (DOS) on or after 3/1/2019, when
the same code for prostheses, sockets, or components for bilateral amputees
are billed on the same date of service bill each item on two separate claim
lines using the RT and LT modifiers and 1 unit of service (UOS) on each claim
line. Do not use the RTLT modifier on the same claim line and billed with 2
UOS. Claim lines billed without the RT and/or LT modifiers, or with RTLT on
the same claim line and 2 UOS, will be rejected as incorrect coding.

Coding Batteries and Chargers Concurrently With a Powered Base Item

Powered base items are those that contain the power source (battery). At the
time that a base item is billed, all necessary batteries and/or battery
chargers are considered as included in the payment for the powered base item.
There is no separate payment for batteries (L7360, L7364, and L7367) and/or
battery chargers (L7362, L7366, and L7368) billed concurrently with a powered
base item.

Payments for items listed in Column II are included in the payment for each
Column I code. Claims for Column II items billed with the provision of a
Column I item will be denied as unbundling.

**Column I** | **Column II**  
---|---  
Base codes with battery, charger and/or power included | Batteries  
L5781 | L7360  
L5782 | L7364  
L5856 | L7367  
L5857 |  
L5858 |  
L5859 | Chargers  
L5973 | L7362  
  | L7366  
  | L7368  
  


Suppliers should contact the DME PDAC contractor for guidance on the correct
coding of these items.

  
CODING VERIFICATION REVIEW

The only products which may be billed using the following list of HCPCS codes
are those for which a written coding verification review (CVR) has been made
by the Pricing, Data Analysis, and Coding (PDAC) contractor and subsequently
published on the Product Classification List (PCL). Information concerning the
documentation that must be submitted to the PDAC for a CVR can be found on the
PDAC web site or by contacting the PDAC. A PCL with products which have
received a coding verification can be found on the PDAC web site. The
effective date of the CVR is included for each code.

Effective for claims with dates of service on or after January 1, 2014:  
L5969

Effective for claims with dates of service on or after January 1, 2021:  
L5856, L5857, L5858, L5973, L5980, L5987

If a product is billed to Medicare using a HCPCS code that requires written
CVR, but the product is not on the PCL for that particular HCPCS code, then
the claim line will be denied as incorrect coding.