CMS Requires PDAC Approval for Six O&P Codes

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In a joint article from the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and the Pricing, Data Analysis, and Coding (PDAC) contractor, the Centers for Medicare & Medicaid Services (CMS) published the continuation of prior authorization for three prosthetic foot system codes and three lower-limb knee-shin prosthesis system codes scheduled for implementation, and provided PDAC coding guidelines that will be effective in 2021.

Effective for claims with dates of service on or after January 1, 2021, the only products that can be billed using codes L-5973, L-5980, L-5987, L-5856, L-5857, and L-5858 are those for which a written Coding Verification Review has been made by the PDAC contractor and published on the appropriate Product Classification List.

The following Healthcare Common Procedure Coding System (HCPCS) codes will require PDAC verification for Medicare reimbursement.

Prosthetic Foot Systems

·        L-5973

ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE

L-5973 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. L-5973 includes foot cover, power source(s) and charger.

·        L-5980

ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM

L-5980 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. L-5980 includes foot cover.

·        L-5987

ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON

L-5987 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. L-5987 includes foot cover.

Additions to Lower-limb Prostheses

·        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-5856 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.

·        L-5857

ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE

L-5857 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.

·        L-5858

ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE

L-5858 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.

To read the article, Prosthetic Feet and Additions to Lower Limb Extremity Prostheses - Correct Coding and Coding Verification Review Requirement, visit a DME MAC jurisdiction website.