Billing and Collections Q&A

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By Lisa Lake-Salmon

Running an O&P facility in today's landscape of enhanced scrutiny and changing billing requirements can leave even the most seasoned billing professional feeling frustrated. If you have a billing question or a question about a denial, "Got FAQs?" can help you sift through the confusion and get you the answers you need. This month's column addresses your questions about coding for microprocessor-controlled knee systems and coordinating component coding with a patient's functional level.

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Q: I am billing for an Össur Power Knee for the first time and am unsure about the correct code to use. With the Medicare audits being conducted on claims for microprocessor-controlled knee systems, the practitioner I work for is adamant that I confirm the correct codes to use. Can you provide me with this information? We are located in Region A.

A: On Feb 8, 2013, the Centers for Medicare & Medicaid Services (CMS) released an article titled Correct Coding and Billing for Electronic/Microprocessor-Controlled Knee (MPK) Systems. The following are the only Healthcare Common Procedure Coding System (HCPCS) codes billable for the Össur Power Knee or any similar swing and stance phase MPK system with powered and programmable flexion/extension assist:

  • L-5828: Addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control.
  • L-5845: Addition, endoskeletal knee-shin system, stance flexion feature, adjustable.
  • L-5848: Addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability.
  • L-5856: Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type.
  • L-5859: Addition to lower extremity prosthesis, endoskeletal knee-shin system, powered and programmable flexion/extension assist control,includes any type motor(s).

For any MPK system, the use of HCPCS codes other than those specified above, either specific codes or not otherwise classified (NOC) codes, for other add-ons, functions, or features is considered unbundling and thus is incorrect coding. To read the full article, which lists all manufacturers for MPK systems and the codes to use when billing for them, visit www.oandp.com/link/197

Q: I just started to work for prosthetic providers in New Jersey, and they are providing a microprocessor-controlled ankle foot system for a patient. I was given L-5973 (endoskeletal ankle foot system, microprocessor controlled feature, dorsiflexion and/or plantar flexion control, includes power source) as the code for billing the device. My boss asked me to show him the Medicare requirement for the patient's functional level to qualify for this device in writing. I have searched everywhere and I am unable to find this information.

A: According to CMS, when billing for a microprocessor-controlled ankle foot system, potential functional ability is based on the reasonable expectations of the prosthetist and treating physician. Your documentation should include the beneficiary's past history, the patient's current condition including the status of the residual limb, the nature of other medical problems, and the patient's desired/anticipated ambulation level based on his or her prior ability. Clinical assessments of the beneficiary's rehabilitation potential must be based on the classification levels listed in the Local Coverage Determination (LCD) for Lower Limb Prostheses. For example: A microprocessor-controlled ankle foot system (L-5973), energy-storing foot (L-5976), dynamic-response foot with multiaxial ankle (L-5979), flex-foot system (L-5980), flex-walk system or equal (L-5981), or shank-foot system with vertical loading pylon (L-5987) are covered for beneficiaries whose functional level is K3 or above. Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given foot type. To review all functional level requirements, visit www.oandp.com/link/198

Lisa Lake-Salmon is the president of Acc-Q-Data, which provides billing, collections, and practice management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact or visit www.acc-q-data.com