My original question and responses….
L5651 – Addition to Lower Extremity, Above Knee, Flexible Inner
Socket, External Frame.
I would like to get a consensus from members on this List to the above
procedure. Since the introduction of the ISNY socket many years back I
have felt the External Frame segment included reinforcement materials
such
has ie: Carbon Fiber, Kevlar, and etc when used. Other have said these
materials are in addition too and the need to bill L5999 or L7510 when
Carbon Fiber,
Kevlar, or etc is added to the basic lay-up of Acrylic resin, Fiber
Glass,
Nylon and/or Perlon.
What is the consensus of this List? I will post the responses.
Al Pike, CP
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agree. In order to construct a rigid frame to support a flexible socket ,
one must include appropriate materials such as those you described.
Hi Al, I saw your note here and wanted to respond to it. I would use the
carbon fiber reinforced code since it is used in the fabrication of the
frame. The external frame code would describe the style of socket. The
use of carbon fiber made the frame stronger and thinner. I hope this is
what you were asking for.
Hello Al, it is my interpretation that this code refers to the
design or type of the socket/frame, not the construction…the
materials utilized would or could be determined by additional
codes, therefore, codes for unique or specific reinforcement
materials would be appropriate.
With regard to the use of a 7510 code, I do not have my manual in
front of me, but a 7000 code is upper extremity and should not be
used in connection with a lower extremity code. Just my opinion.
I am all for billing for what I do, but I have not
billed for additional reinforcements on my frame lay-ups. Acrylic code and
ultra-light code along with the frame code adequately reimburses for the
materials I believe. Some have a less reinforced lay-up than others. I just
make a little less profit on the limbs that are significantly more
reinforced than the standard. Great question,
When the code was first introduced, I believe it was purely in a polyester
resin format with attempts to reinforce the frame due to the cutouts with
corrugations to mechanically introduce strength. Polyester resin remains to
this day the standard default for thermosetting resin lamination on which the
Medicare reimbursement rates were based on. With the advent of high strength
fabrics such as Kevlars and carbon fibers and high strength resins such as
epoxies and acrylics and blends, the problems of frame strength were
adequately addressed. However, the additional cost of these materials needed
to produce these improved frames were not added into the base reimbursements
allowances for the Medicare fees presumably at Medicare’s directive. Rather,
Medicare created a separate code to identify when these materials were used
in the fabrication process to gain higher strength to weight ratios and
established an allowable to acknowledge the increased cost associated with
the use of these materials. I believe that is still the underlying
philosophy that stands today.
I use the “Ultra-light materials” code to cover the cost of carbon in
the external frame (or any laminated socket, for that matter.)
You bill for carbon fiber using the code for “Ultra light material (carbon
fiber, titanium metal, etc)”. But this brings up another point about
flexible sockets / external frames. Unless you cut windows in the rigid
frame to allow the flexible socket to flex, all you have done is add bulk,
weight and cost to a prosthesis. So if you use the flexible socket code,
and you reinforce the frame and bill for carbon fiber, and you go to the
trouble to fabricate it, cut windows in your reinforced frame and let the
patient get the benefit from socket flexibility.
The way I see it is this: If there is extra expense incurred in order to
manufacture the frame than the extra code can be justified. For example, I
can laminate a frame using no carbon at all and for that matter even without
the use of acrylic resin. However, if the ultra light code is used than this
is in direct conflict with the intent of that code i.e.: to create an
ultra light SYSTEM, which the socket is a part of. We all probably use
carbon in the manufacture of our frames but this does not mean that the code
should be used every time either. If you use all carbon fiber, or more than
usually used for a specific reason that can be justified to benefit the
patient, instead of just some reinforcing here and there than I feel it is
justified.
Hi Al: You could use the L5629 or L5631, but nothing else in addition to
L5651. You could argue that these two codes are included, but I do not
believe it would be incorrect to use either of the two codes. Never unlisted
codes for the Kevlar.
If you used that amount of fiberglass, carbon fiber and acrylic resin to make
your standard quad sockets (quad was the available socket when ISNY was
introduced), then I agree that you are correct, if not, then I believe that
it is an add on. Acrylic resin has always been additional as it is a few
pennies more expensive than polyester.
Since Medicare pays $952.62 on that code, I think it is reasonable for it to
include the cost of the inner socket material and the carbon Braid or
matting used in the lamination. Proflex (or equivalent) isn’t that
expensive, carbon isn’t that expensive, carbon braid is a little more
expensive… anyway, I’m sure people can make it work with just the L5651,
though I can’t say I’m surprised that L5999 was recommended. L7510 is flat
out crazy in my mind, that is a repair code!!!
I thought L5950 was meant to cover light weight materials, ie carbon,
fiber, titanium etc?
I think it appropriate to bill for the carbon add-on. I think you should be
billing, too, for the “acrylic” add-on you referred to in the basic lay-up.
I believe polyester resin is what is inclusive of a base socket lamination
historically.
Consider a flexible socket with a polypropylene outer rigid frame and how
both those “things” would be absent.
I’ve always understood the 5651 code a designation of a particular
socket/frame design, which would be the flexible wall or brim housed in a
rigid frame. The addition of reinforcements such as carbon or Kevlar would
be an addition to that.
You are correct, Al, but it refers only to the labor and materials required
to build one, not the socket fitting that is included in the base code
5321. For a socket replacement it would be an addition to 5701 just as a
5649 CATCAM-IC socket, 5650 Total contact, or 5652 suction, would be.
