The four Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued two joint publications regarding correct coding for the LIM Innovations Infinite Socket™ and the Martin Bionics Socket-less Socket™. Summaries follow:
Infinite Socket: If this product is included as part of a complete prosthesis, the base socket is included as part of the prosthesis base code. Choose the appropriate base code depending upon the type provided: L-5321 (socket above knee, molded socket, open end, SACH foot, endoskeletal system, single axis knee) or L-5590 (preparatory, above knee – knee disarticulation ischial level socket, non-alignable system, pylon no cover, SACH foot, laminated socket, molded to model0. The add-on codes and choice of suspension must be included on the same claim for the complete prosthesis (i.e., the claim that includes one of the above codes).
If this product is provided as a replacement to an existing socket, in addition to the add-on codes and choice of suspension), use L-5701 (replacement, socket, above knee/knee disarticulation, including attachment plate, molded to patient model).
Add-on L-Codes used to describe the type of suspension incorporated into the socket may be added to the claim. Use of more than one type of suspension is considered incorrect billing, (same/similar item). The prosthetic record must include specific, detailed information justifying the need for each additional feature.
Socket-less Socket: The product is supplied as a prefabricated kit and fit directly to the beneficiary. The existing L-Codes for base prosthesis and replacement sockets used for above-knee lower-limb prosthesis sockets are not appropriate for this product. Existing base and socket codes describe items that enclose the residual limb to provide the stability, proprioception, and suspension necessary for the effective use of the prosthetic limb. The appropriate code for the Socket-less Socket is L-5999 (lower extremity prosthesis, not otherwise specified). L-5999 is billed as one unit of service (UOS) to describe all features and functions of the entire product. When L-5999 is billed, the claim must include a narrative description of the item that includes the manufacturer and the brand name or number, and information describing whether this socket is a new socket included as part of a complete prosthesis or a replacement socket for an existing prosthesis. If the socket is part of a complete prosthesis, specify whether the preparatory (L-5590) or definitive (L-5321) base code was used for the base prosthesis.
Add-on L-Codes used to describe the type of suspension incorporated into the socket may be added to the claim. Use of more than one type of suspension is considered incorrect billing, (same/similar item).