CGS, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor (DME MAC), announced it will be implementing a service-specific medical review edit for Healthcare Common Procedure Coding System (HCPCS) code L-5856K3 (Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type). CGS said the edit is the result of data demonstrating a high claims payment error rate for this product category.
Claims subject to this edit will be developed for additional documentation. Suppliers receiving a development letter should follow the instructions contained in the letter for the documentation requested, including, but not limited to:
1. Detailed proof of delivery for all items provided
2. Preliminary dispensing order (if items were dispensed prior to obtaining a detailed written order)
3. Detailed written order
4. The patient’s medical records that support the medical necessity for the items billed
5. Treating physician’s and/or prosthetist’s medical records that document the beneficiary’s current functional capabilities and expected functional potential, the timeframe to reach and maintain functional state, and the beneficiary’s motivation to ambulate
6. Any other pertinent documentation
7. Advance Beneficiary Notice on file should be submitted with other requested documentation
Relevant medical records consist of physician notes, non-physician clinical notes, and non-physician clinical evaluations that verify the patient’s condition meets coverage criteria. The source of these records may be a physician’s office, hospital, nursing home, home health agency, etc. Evaluations used to determine coverage must have been performed and recorded prior to delivery and performed by a clinician who does not have a financial relationship with the supplier.
The information must be received within 45 days of the date of the letter or the claim will be denied. Additional information and documentation requirements for HCPCS code L-5856 can be found on the CGS Medicare website.