Healthcare Common Procedure Coding System code L-5856 (addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type), is slated for a widespread prepayment review by CGS Administrators, the Jurisdiction C Durable Medical Equipment Medicare Administrative Contractor. L-5856 is used as an addition code to prosthetic knee components that incorporate the use of a microprocessor to control the knee during both swing and stance phase of the gait cycle.
CGS announced that the prepayment review will begin on or around June 15 and will occur across all provider groups that submit claims including L-5856. CGS suggested that providers review the current local coverage determination and policy article for lower-limb prostheses and reference the CGS documentation checklist for lower-limb prostheses.
The American Orthotic & Prosthetic Association (AOPA) stated that while the CGS documentation checklist is useful, it does not contain specific information regarding coverage requirements for microprocessor-controlled prostheses. AOPA encouraged its members to work with their physician partners to ensure that documentation regarding the need for a microprocessor-controlled prosthetic knee is in the patient’s medical record, that the documentation addresses the need for a microprocessor knee over a conventional prosthetic knee, and that it supports the need for K3 or higher functional level components.