DME MACs Advise on Appropriate Coding, Billing for Lower-Limb Prosthetic Covers

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have issued an article to educate suppliers and providers about proper billing and coding for certain lower-limb prosthetic covers and protective covering systems. They said they have received a high volume of submitted claims for lower-limb prosthetic covers and protective covering systems for the same lower-limb prosthesis, and that the need for both of these is rare. The affected covers are: 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). The affected covering systems are: L-5962 below knee flex cover system), L-5964 (above knee flex cover system), and L-5966 (hip flexible cover system).

According to the article, lower-limb prosthetic covers (L-5704 through L-5707) 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, L-5964, and L-5966) are specialized covers intended to be worn over an existing prosthesis. They are used by a beneficiary who has 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 L-5704 through L-5707. They are not covered for cosmetic or convenience reasons, or for everyday usage in a typical environment. This type of product is separate from the covering that is already reimbursed as part of L-5704 through L-5707 and is rarely necessary.

The article further stated that documentation to support medical necessity of a protective outer-surface covering system (L-5962, L-5964, and L-5966) must indicate the type of extraordinary activities that would justify the need for extra protection afforded by this highly durable item, and when billing for these items, information regarding the type of protective cover provided (i.e., manufacturer name, make, model, or type) must be included on claims in order to ensure correct coding.

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