Prosthetics Codes Added for Prior Authorization

Home > Articles > Prosthetics Codes Added for Prior Authorization

The Centers for Medicare & Medicaid Services (CMS) announced that six Healthcare Common Procedure Coding System (HCPCS) prosthetics codes will require Medicare prior authorization as a condition of payment.

The initial implementation of prior authorization is scheduled for May 2020 on a limited basis in Pennsylvania, Michigan, Texas, and California, one state from each of the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) jurisdictions. Nationwide implementation is scheduled for late 2020.

The HCPCS codes for three microprocessor prosthetic knees, a microprocessor prosthetic foot, and two K3 prosthetic feet and their descriptors are as follows:

·        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-5857 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type

·        L-5858 Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type

·        L-5973 Endoskeletal ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source

·        L-5980 All lower extremity prostheses, flex foot system

·        L-5987 All lower extremity prosthesis, shank foot system with vertical loading pylon

Prior to the CMS announcement, the American Orthotic and Prosthetic Association (AOPA) said it received an email from CMS that stated the following:

·        CMS does not intend to significantly expand the number of lower-limb prostheses subject to prior authorization in the future.

·        CMS understands the need for timeliness in making prior authorization decisions.

·        DME MACs will provide education to providers when prior authorization requests are not initially approved.

·        Affirmative prior authorization decisions will guarantee payment and reduce likelihood of audits down the road.

AOPA said it is "encouraged by CMS' efforts" to address AOPA's concerns about prior authorization, and that it will "monitor the process to ensure that it does not lead to unnecessary delays in delivery of clinically appropriate prosthetic care…."

To read the document, visit the Federal Register.