In a joint publication, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) announced revisions to the Lower Limb Prostheses Policy Article, which will be effective August 1.
Several new codes will now require K-level modifiers: L5827, L5850, L5855, L5925, L5926, L5968, and L5988.
Modifiers now include GA, GY, GZ, K0, K1, K2, K3, K4, KX, LT, and RT.
The revisions are as follows:
Policy-specific documentation requirements
- Removed: K-level modifier information that pertained to claims submitted for knee, foot, ankle, and hip Healthcare Common Procedure Coding System (HCPCS) codes
- Revised: “This expectation of functional ability information must be clearly documented and retained in the prosthetist’s records” to “Functional ability information must be clearly documented and retained in the prosthetist’s records”
- Revised: “The simple entry of a K modifier in those records is not sufficient” to “The simple entry of a K-level modifier in those records is not sufficient”
Modifiers
- Revised: “GA, GY, GZ, KX, LT, and RT Modifiers” to “GA, GY, GZ, K0, K1, K2, K3, K4, KX, LT, and RT Modifiers”
- Added: “K-level modifiers are K0, K1, K2, K3, and K4. These modifiers are used to indicate the expected beneficiary functional level. Information to support the K-level modifier must be retained in the supplier’s files and available to the DME MAC upon request.”
- Added: K-level modifier information that pertains to claims submitted for knee, foot, ankle, and hip HCPCS codes (relocated from the Policy Specific Documentation Requirements section)
- Added: L5827 to the HCPCS codes that must be submitted with a K-level modifier, as clarification
- Added: L5845, L5850, L5855, L5925, L5926, L5968, and L5988 as HCPCS codes that must be submitted with a K-level modifier (as of dates of service on or after August 1)
- Added: “Claim lines billed for these lower limb prosthetic HCPCS codes without a K-level modifier will be rejected as missing information,” as clarification
Coding Guidelines
- Revised: “Codes L5940, L5950, and L5960 for ultralight materials may only be used when materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis” to “Codes L5940, L5950, and L5960 for ultralight materials may only be used when materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis (i.e., L5301, L5312, L5321, L5331, L5341, L5700, L5701, L5702, or L5703).”
- Revised: “microprocessor controlled knee” to “microprocessor-controlled knee”
- Revised: “K-Level modifier” to “K-level modifier”
- Revised: “Included features in the code are described by L5845 and L5848” to “Features included in the code are described by L5845 and L5848.”
- Revised: “The use of these codes can be used to fully describe additional features or functions not found in the prosthetic foot system (L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979 L5980, L5981 and L5987)” to “These codes can be used to fully describe additional features or functions not found in the prosthetic foot system (L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987).”
- Revised: “Use of L5968, L5982, L5984 or L5986 is based on the beneficiary’s K-level modifier (K0-K4), as referenced in the LCD” to “Use of L5982, L5984, L5985, or L5986 is based on the beneficiary’s K-level modifier (K0-K4), as referenced in the LCD.”
- Revised: “L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987.” to “L5968, L5969, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987,” as clarification
- Revised: “microprocessor controlled foot” to “microprocessor-controlled foot”
- Revised: “There is no separate payment for batteries (L7360, L7364, and L7367) and/or battery chargers (L7362, L7366, and L7368) billed concurrently with a powered base item” to “There is no separate payment for batteries (L7360, L7364, and L7367) and/or battery chargers (L7362, L7366, and L7368) billed concurrently with a powered base item (L5781, L5782, L5856, L5857, L5858, L5859, and L5973).”
- Revised: The format of the table that pertains to items in Column II which are included in the payment for each Column I code, as clarification
To read the “Policy Article Revisions Summary for June 18, 2026,” visit the Noridian website.
