The four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication regarding coding for the LIM Innovations Infinite Socket™ TF C1, which is a prefabricated modular transfemoral-level design that has recently become available. This product uses four struts that extend from the base to an adjustable brim to form the structure of the item.
According to the publication, the existing Healthcare Common Procedure Coding System (HCPCS) L-Codes used for transfemoral-level prosthesis sockets describe items that enclose the residual limb to provide the stability, proprioception, and suspension necessary for the effective use of the prosthesis. This product is sufficiently different in design and construction that existing L-Codes for sockets and socket additions are inappropriate for use with this product, the publication stated. Therefore, claims for this item using existing L-Codes will be denied as incorrect coding.
The publication goes on to state that as a defined-benefit program, the first requirement for any item to be potentially eligible for Medicare reimbursement is that the item must qualify for inclusion into an existing benefit category. There is no evidence in the clinical literature demonstrating that this design is able to function effectively as a socket for a lower-limb prosthesis. Therefore, the item does not qualify for inclusion in the Artificial Limbs benefit category. The correct code to use for Medicare claims for this item is A-9270 – noncovered item or service.
This coding determination is all-inclusive. Separate billing for options, accessories, additions, etc. used with this product will be denied as unbundling.
For additional information on coverage, coding, and documentation for prosthetic limbs, read the Lower Limb Prosthesis Local Coverage Determination and related Policy Article. For questions about correct coding, contact the Pricing, Data Analysis and Coding (PDAC) contractor Contact Center at 877.735.1326, or by e-mailing the DME PDAC Contact Form.