The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) issued a joint publication to educate suppliers and providers about appropriate coding and billing of lower-limb prosthetic covers and covering systems. The publication said that the DME MACs receive a high volume of claims for lower-limb prosthetic covers and protective covering systems for the same lower-limb prosthesis, even though the need for both is rare.
Lower limb prosthetic covers are billed under codes L-5704 (custom shape cover bk), L-5705 (custom shape cover ak), L-5706 (custom shape cvr knee disart), and L-5707 (custom shape cvr hip disart). They are complete products and afford shape, protection, and waterproofing for normal daily usage of the prosthesis. They offer sufficient protection and weatherproofing for patients who require lower-limb prostheses.
Protective outer surface covering systems L-5962 (below knee flex cover system), L-5964 (above knee flex cover system), and L-5966 (hip flexible cover system) are specialized covers intended to be worn over an existing prosthesis. They are used by people who have special needs for protection against unusually harsh environmental situations where it is necessary to protect the lower-limb prosthesis beyond the level of that which is afforded by lower-limb prosthetic covers. Protective outer surface covering systems are not covered for cosmetic or convenience reasons, or for everyday use in a typical environment. This type of product is separate from the covering that is reimbursed as part of L-5704 through L-5707 and is rarely necessary.
Documentation to support the medical necessity of a protective outer surface covering system must indicate the type of extraordinary activities that would justify the need for extra protection afforded by this highly durable item. When billing for them, information regarding the type of protective cover provided (i.e., manufacturer name, make, model, or type) must be included on claims to ensure correct coding.
