evekhm/cms_iom_500 huggingface dataset:
Article - Lower Limb Prostheses - Policy Article (A52496)
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 beneficiarys 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
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 atreating practitionerdetermines 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: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,An irreparable change in the condition of the device, or in a part of the device resulting in the need for a replacement; or,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
Article - Lower Limb Prostheses - Policy Article (A52496)
CONTINUED MEDICAL NEEDFor 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.MODIFIERSLT 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 GUIDELINESREPAIR AND LABOR CODINGCode 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 assessmentEvaluation of problems regarding the fit or function of the prosthesisGeneral beneficiary education or gait instructionProgramming of electronic componentry
Article - Lower Limb Prostheses - Policy Article (A52496)
Evaluation to determine the need for a repair or adjustment or follow-up assessmentEvaluation of problems regarding the fit or function of the prosthesisGeneral beneficiary education or gait instructionProgramming of electronic componentrySUSPENSIONCode 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
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 theinsert 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
PROSTHETIC SYSTEMSExoskeletal 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 CONNECTORSL5991 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
SOCKETSCodes 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
PROTECTIVE COVERSLower 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, andL5707.FOOT COVERSFoot covers are included in the codes for a prosthetic foot component and are not separately payable.
Article - Lower Limb Prostheses - Policy Article (A52496)
KNEESWith 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).
Article - Lower Limb Prostheses - Policy Article (A52496)
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 joints 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
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.
Article - Lower Limb Prostheses - Policy Article (A52496)
ANKLE AND LOWER EXTREMITY MOTION UNITSCodes 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 ankles dorsiflexion angle and maintain it throughout swing phase. The product provides an accommodation of changing heel heights without the users 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
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 beneficiarys 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
FEETAddition 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 Systems 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.
Article - Lower Limb Prostheses - Policy Article (A52496)
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.