Correct Coding and Billing for Microprocessor -
Controlled Knee Systems (A51532)
Recent claim reviews note that suppliers are billing miscellaneous code L5999 (lower extremity prosthesis, not otherwise classified) for various elements of microprocessor-controlled knee systems such as the Otto Bock C-Leg®, C-Leg Compact™, or Genium™. This use of miscellaneous codes is not correct. For example, functions performed by the on-board microprocessors and/or sensors (e.g., “real-time gait assessment,” “electronically controlled static stance regulator, adjustable”), or programming necessary for use, must not be billed using L5999. Use of additional codes is limited to those specified below. There is no separate billing and reimbursement for any other features or functions since the allowance for all functions and features is included in the payment for codes listed below.
Base code L5856
The following are the only Healthcare Common Procedure Coding System (HCPCS) codes billable for C-Leg®, Genium™ or any similar microprocessor controlled knee systems:
The following are the only HCPCS codes billable for C-Leg Compact™ or any similar microprocessor controlled knee systems:
Recent claim reviews note that suppliers are billing miscellaneous code L5999 (lower extremity prosthesis, not otherwise classified) for various elements of microprocessor-controlled knee systems such as the Otto Bock C-Leg®, C-Leg Compact™, or Genium™. This use of miscellaneous codes is not correct. For example, functions performed by the on-board microprocessors and/or sensors (e.g., “real-time gait assessment,” “electronically controlled static stance regulator, adjustable”), or programming necessary for use, must not be billed using L5999. Use of additional codes is limited to those specified below. There is no separate billing and reimbursement for any other features or functions since the allowance for all functions and features is included in the payment for codes listed below.
Base code L5856
The following are the only Healthcare Common Procedure Coding System (HCPCS) codes billable for C-Leg®, Genium™ or any similar microprocessor controlled knee systems:
- L5828 - addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
- L5845 - addition, endoskeletal knee-shin system, stance flexion feature, adjustable
- L5848 - addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability
- L5856 - addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type
The following are the only HCPCS codes billable for C-Leg Compact™ or any similar microprocessor controlled knee systems:
- L5828 - addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
- L5845 - addition, endoskeletal knee-shin system, stance flexion feature, adjustable
- L5858 - addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type
- HCPCS code L5930 (addition, endoskeletal system, high activity knee control frame) may only be used with K4 functional level patients.
- Do not bill separately at initial issue miscellaneous code L5999 for the pylon with sensor for use with microprocessor controlled knee systems. It is considered included in the payment for L5856 and L5858.
DMEPOS Activities Revealed in OIG's 2012 Work Plan
Content provided by The O&P EDGE
The Department of Health & Human Services (HHS), Office of the Inspector General (OIG), has issued its Work Plan for fiscal year (FY) 2012, which reflects a continued increase in OIG’s focus on suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). This annual publication is released in advance of the coming year. It provides healthcare industry stakeholders with a broad overview of the OIG’s activities in the coming year as they relate to its enforcement priorities and issues it will review and evaluate during that fiscal year. OIG Work Plan priorities often result in additional enforcement action, significant change in Centers for Medicare & Medicaid Services (CMS) policy, or both.
One O&P-specific project is new to this year’s Work Plan:
The Department of Health & Human Services (HHS), Office of the Inspector General (OIG), has issued its Work Plan for fiscal year (FY) 2012, which reflects a continued increase in OIG’s focus on suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). This annual publication is released in advance of the coming year. It provides healthcare industry stakeholders with a broad overview of the OIG’s activities in the coming year as they relate to its enforcement priorities and issues it will review and evaluate during that fiscal year. OIG Work Plan priorities often result in additional enforcement action, significant change in Centers for Medicare & Medicaid Services (CMS) policy, or both.
One O&P-specific project is new to this year’s Work Plan:
- Collection of Surety Bonds for Overpayments Made to DMEPOS Suppliers. OIG will review CMS’s use of surety bonds, a fraud prevention/limitation measure, to recover overpayments made to DMEPOS suppliers. OIG will determine the amount of overpayments CMS sought and recouped through DMEPOS surety bonds, and also identify barriers to surety bond collection. Certain DMEPOS suppliers must provide and maintain a surety bond of no less than $50,000, per BBA, § 4312(a)(16).
- Medicare Enrollment and Monitoring for DMEPOS Suppliers. OIG will review and assess Medicare contractors’ use of enrollment-screening mechanisms and post-enrollment monitoring activities for DMEPOS suppliers to identify applicants that pose fraud risks to Medicare and the extent to which applicants omitted ownership information on enrollment applications. Pursuant to CMS’ Medicare Program Integrity Manual, Medicare contractors must conduct prescreening, verification, validation, and final processing of Medicare provider enrollment applications.
- Medicare Qualifications of Orthotists and Prosthetists. OIG will review the credentials of a sample of providers submitting custom-fabricated O&P claims to determine the extent to which Medicare paid unqualified practitioners in 2009 and the extent to which CMS provides oversight of credentialing of orthotists and prosthetists. OIG will also assess whether CMS provided guidance to state licensing boards and industry on how to define a “qualified practitioner” of O&P. Pursuant to special payment rules for certain custom-fabricated prosthetics and custom-fabricated orthotics, no payment will be made for such items unless provided by a qualified practitioner as defined in the Social Security Act, § 1834(h)(1)(F). OIG concluded that the qualifications of orthotic suppliers varied, with noncertified suppliers most likely to provide inappropriate devices and services.
- Medicare Supplier Acquisition Costs for Back Orthoses. OIG will compare supplier acquisition costs to the Medicare reimbursement amount for the back orthosis procedure code L-0631. Back orthoses are covered by Social Security Act, § 1832(a)(2), and are supplied by Medicare DMEPOS suppliers, who purchase back orthoses from wholesalers or directly from orthotics manufacturers. OIG has encountered suppliers and Internet retail shops that can provide these back orthoses for prices significantly lower than Medicare reimbursement rates of $929.
- Frequency of Replacement of Supplies for Durable Medical Equipment. OIG will review the compliance of DMEPOS suppliers with Medicare requirements for frequently replaced durable medical equipment (DME) supplies to determine whether payments for such supplies met Medicare requirements…. OIG will select a sample of claims for frequently replaced supplies. For DME supplies and accessories used on a periodic basis, the order or certificate of medical necessity must specify the type of supplies needed and the frequency with which they must be replaced, used, or consumed, according to CMS’ Medicare Program Integrity Manual. Further, a beneficiary or a beneficiary’s caregiver must specifically request refills of repetitive services and/or supplies before a supplier dispenses them. Also, a supplier may not initiate a refill of an order and a supplier must not automatically dispense a quantity of supplies on a predetermined regular basis.
- Medicare Payments for DME Claims with Modifiers. OIG will review and determine the appropriateness of Medicare Part B payments to DME suppliers that submitted claims with certain modifier codes. For certain items to be covered by Medicare, DME suppliers must use modifiers to indicate that they have the appropriate documentation on file and provide, upon request, the documentation to support their claims for payment.
- Competitive Bidding Process for Medical Equipment and Supplies. OIG will review the process CMS used to conduct competitive bidding and subsequent pricing determinations for certain DMEPOS items and services in selected competitive bidding areas under Rounds 1 and 2 of the competitive bidding program. Federal law, MIPPA, § 154(a)(1)(E), requires OIG to conduct post-award audits to assess this process.
- Medicare DMEPOS Competitive Bidding Program: Supplier Solicitation of Physician Prescribing. OIG will interview prescribing physicians to determine the extent to which suppliers participating in the competitive bidding program are soliciting physicians to prescribe certain brands or modes of delivery of covered items that are more profitable to suppliers. OIG will also examine billing patterns to identify changes resulting from competitive bidding.
PDAC to Require Product Labeling
Content provided by The O&P EDGE
The Medicare Pricing, Data Analysis, and Coding contractor (PDAC) has announced that effective February 1, 2012, any product that is subject to a PDAC coding review and identification by the Centers for Medicare & Medicaid Services (CMS) and its contractors, including the PDAC, Durable Medical Equipment Medicare Administrative Contractors (DME MACs), DME Program SafeGuard Contractors, and Zone Program Integrity Contractors (ZPICs), must be permanently labeled. According to the PDAC, the label must contain the manufacturer’s name, product name, and model number. The label on any product delivered to the beneficiary must be identical to the label on the product submitted for coding verification and must be permanent in nature.
While the PDAC advises complete and permanent labeling for all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), the O&P-specific products that must be labeled at this time include:
All additional product labeling requirements as described in DME MAC Local Coverage Determinations (LCDs) and/or policy articles must also be met.
PDAC also advises that the list is subject to change.
The Medicare Pricing, Data Analysis, and Coding contractor (PDAC) has announced that effective February 1, 2012, any product that is subject to a PDAC coding review and identification by the Centers for Medicare & Medicaid Services (CMS) and its contractors, including the PDAC, Durable Medical Equipment Medicare Administrative Contractors (DME MACs), DME Program SafeGuard Contractors, and Zone Program Integrity Contractors (ZPICs), must be permanently labeled. According to the PDAC, the label must contain the manufacturer’s name, product name, and model number. The label on any product delivered to the beneficiary must be identical to the label on the product submitted for coding verification and must be permanent in nature.
While the PDAC advises complete and permanent labeling for all durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), the O&P-specific products that must be labeled at this time include:
- Pneumatic compression sleeves/garments.
- Compression stockings.
- Diabetic shoes: Labels should be on both items of the pair.
- Diabetic shoe inserts: Includes custom fabricated in a central facility. Labels must be on both items of the pair.
- Orthotics: Prefabricated and custom fabricated by a manufacturer/central fabrication facility and then sent to someone other than the patient.
- Prosthetics: Prefabricated components (e.g. feet, knees).
All additional product labeling requirements as described in DME MAC Local Coverage Determinations (LCDs) and/or policy articles must also be met.
PDAC also advises that the list is subject to change.
Follow up to the Owners and Managers Meeting in Sandestin
Thank you to Jenna Calomeris of Ossur for providing the following documents regarding Questionable Billing by Suppliers of Lower Limb Prostheses, the OIG report and the Public Meeting Agenda on June 7, 2011 at CMS.
As you can imagine, RAC Audits and Medicare in general were a hot topic at the meeting and we appreciate Jenna forwarding this information.
OIG has made several recommendations to Medicare.
1. Closer monitoring of submitted claims by the MAC's.
2. Require a face-to-face meeting between the patient and the prescribing physician before delivering a prosthesis.
3. Revise Medicare's local coverage determinations (LCD) for lower limb prostheses by:
a) clarifying the functional level definitions and
b) requiring another licensed professional, such as a physical therapist, to assess the patient's functional level.
Thank you to Jenna Calomeris of Ossur for providing the following documents regarding Questionable Billing by Suppliers of Lower Limb Prostheses, the OIG report and the Public Meeting Agenda on June 7, 2011 at CMS.
As you can imagine, RAC Audits and Medicare in general were a hot topic at the meeting and we appreciate Jenna forwarding this information.
OIG has made several recommendations to Medicare.
1. Closer monitoring of submitted claims by the MAC's.
2. Require a face-to-face meeting between the patient and the prescribing physician before delivering a prosthesis.
3. Revise Medicare's local coverage determinations (LCD) for lower limb prostheses by:
a) clarifying the functional level definitions and
b) requiring another licensed professional, such as a physical therapist, to assess the patient's functional level.
| Download the OIG Report |
| CMS Agenda June 7, 2011 |
| CMS preliminary decision L5987 Freedom Thrive |
