From: Aryeh Lax
Date: Thu Dec 9, 2004 8:19:20 PM US/Pacific
To: [email protected]
Subject: responses to coding issues
Original questions:
1. Does L5301 include the foam cover?
2. Is the inclusion of an air expulsion valve and a suspension sleeve
enough to justify coding for a suction BK socket that is otherwise
conventional? How do you define the usage of the code for a suction BK
socket?
3. What #$^*#@$%@# book explains these issues in enough detail to keep
out of hot water. I realize that coding issues are constantly
undergoing debate and clarification, but is there a fairly reliable,
detailed, current source for code definitions?
Thanks in advance,
Aryeh
L5301 replaced L5300 specifically not to include the cover because some
people don’t want a cover. The reimbursement was virtually identical
for the two fees minus the cost of L5704 which used to be described as
Replacement Cover and now is just BK Cover. You are correct for
#2. Valve only also makes it justifiable to bill suction, with or
without sleeve. I believe sleeve alone is also ok, as is silicone roll
on with a valve. But silicone roll on with pin lock does not allow use
of suction code, at least with Medicare. They feel that suction is
included in silicone and pin lock and it cannot be billed
separately. However with private insurance……………? As for #3,
do you get the yearly DMERC CD that has the manual and quarterly
updates? If not, let me know and I’ll burn you a copy and mail it to
you. The 2004 CD has references back at least 4 years. Keep in mind
that I am in Region D and the CD may only be for Region D, but it still
would be a good reference. Ain’t it fun?
L5300 did include the cover, but L5301 does not.
L5301 BELOW KNEE, MOLDED SOCKET, SHIN, SACH FOOT, ENDOSKELETAL SYSTEM
Codes L5647 and L5652 describe a modification to a prosthetic
socket(note prosthetic socket!) that incorporates a suction valve in
the design. Codes L5647 and L5652 must not be billed with code L5671
since code L5671 includes a suction valve. Codes L5647 and L5652 are
not appropriate codes to be used for gel liners (L5673, L5679, L5681,
L5683).
Per Medicare: See www.cignamedicare.com/dmerc/index.html and click
on the Medical Review Prompt. Select LMRP (Local Medical Review Policy)
and
select Current LMRP and LCD’s. Scroll down to Lower Extremity
Prosthetics
and all the info you need on lower extremity prosthetics is here. Go to
the
section “coding guidelines below the codes descriptions. You will find
the
infor on suction code L5647 here.This is a great source for you to know
how
to bill items. This is Region D’s guidelines.
L5301 does not include the cosmetic cover which is an add-on code L5704.
The answer to your #2 question is yes that is a true BK suction
prosthesis.
The answer to #3 is to contact AOPA- they have resources available as
well as coding seminars.
Aryeh
