Update: AOPA’s Analysis of Proposed Lower Limb Prosthetic Policy


On Thursday, July 16th, the four DME MACs, released their joint proposal for substantial modifications to the Local Coverage Determination and Policy Article applicable to Medicare reimbursement for lower extremity prosthetics. AOPA has now examined the proposed changes and has complied a comprehensive summary of the proposed LCD and Policy Article, accompanied by an Executive Summary (access both the AOPA Executive and Comprehensive Summary materials here)

Executive Summary of Key Issues in the Proposed DME MAC Changes to the Local Coverage Determination Relating to Reimbursement for Lower Limb Prosthetics

  • Creates clear definitions and distinctions between immediate, preparatory, and definitive prostheses, and also raises question as to whether addition codes maybe billed as part of a preparatory prosthesis. Note: Restricting delivery of a definitive prosthesis until after completion of a rehabilitation program may not be in the best interest of the beneficiary nor is it cost effective.
  • For immediate, preparatory , and definitive prostheses, there is language that states that they are all inclusive and that separate components billed with prosthetic base codes will be denied as either not medically necessary or as unbundling, which is likely to adversely impact patient care for Medicare beneficiaries. Historically, the L Code system has recognized that the use of addition codes is not unbundling.
  • All additions, adjustments, modifications, replacements, etc. for the first 90 days after delivery of the prosthesis are included in the Medicare payment for the prosthesis. Proposed policy does not allow for socket changes or component changes on preparatory prostheses for 90 days following delivery of the preparatory prosthesis.
  • Requirements that patients must have a healed incision site and must be starting a rehabilitation program will create additional documentation hurdles for prosthetic providers which also may further delay patient’s care.
  • The new policy contains requirements that in order for the initial definitive prosthesis to be covered, the patient must have successfully completed a rehabilitation program. The policy also requires an in-person medical evaluation with the ordering physician or a licensed certified medical professional (LCMP) with no financial interest in payment of the claim to be designated by the ordering physician.
  • The draft LCD indicates that socket inserts represented by L5673, L5679, L5681, and L5683 represent custom fabricated socket inserts and will only be covered when non-custom socket interfaces do not provide an adequate interface between the socket and the residual limb.
  • Suction suspension systems will be considered not medically necessary for functional level 1 patients. Note: CMS and/or the DME MACs do not have the authority to determine the safety and effectiveness of prosthetic services.  This responsibility lies exclusively with the Food and Drug Administration (FDA).
  • The consolidation of HCPCS codes L5976, L5980, L5981, and L5987 to a temporary code (KXXX1) and L5982, L5984, and L5986 to a temporary code (KXXX2) will severely impact the patient’s choice of prosthetic feet and ankles that best meet their individual clinical needs—resulting in a Medicare standardized approach to re-bundling and reducing codes arbitrarily translating into lower quality care for Medicare amputees, and so lesser mobility and reduced independence.
  • While not a new policy, the draft LCD includes language that states that prosthetic skins are only covered in situations where a patient may be exposed to unusually harsh environmental conditions and provides protection beyond what is inherently provided by prosthetic covers.
  • Draft policy does not provide coverage for amputees that did not participate in a rehabilitation program immediately following their amputation but are now candidates for prosthetic intervention.
  • The requirement that the prosthesis must provide the patient with “the appearance of a natural gait” should not preclude coverage of a prosthesis that is otherwise functional (the truth is that for some patients who can attain excellent mobility, natural gait is not possible, and again this approach simply creates another audit complication, where CMS contractors (RACs and others) can claim that since the patient did not attain the “appearance of a natural gait”, the cost of the entire prosthesis can be reversed as not medically necessary. The requirement that the functional level assessment must include documentation that the patient has sufficient cognitive, cardio-pulmonary, and neuro-muscular control to ambulate effectively at the determined functional level is extremely discriminatory to patients who may be compromised in these areas without bearing on their ability to efficiently ambulate with a prosthesis.   The elimination of patient potential from the revised functional level categories may significantly limit access to higher functional level componentry for patients who are progressing adequately through the rehab process.
  • If the patient utilizes, or if the patient’s records show that Medicare has paid for, any form of mobility aid (cane, crutches, walker, etc.) access to higher quality prosthetic components will be severely limited, regardless of your functional capabilities. The use of a walker, crutches, or a cane e.g., for nighttime bathroom access, or periodic situation of soreness or skin irritation from greater than normal activity) should not, in and of itself, limit a patient to a specific functional level classification.
  • The draft LCD reiterates two troublesome policies which have caused significant headaches and financial losses to O&P professionals. First, the document restates that the prosthetist’s note will not be considered as part of the patient’s medical record for purposes of establishing medical necessity, which relies on the physician records (prosthetist notes may be used only in corroborating things stated in those physician records).  Second, the document also reiterates the new proof of delivery polices insofar as the HCPCS coding descriptor, no matter how specific it is, is not considered sufficient to describe the device—any device without a serial number, part number or model number is at severe risk of not being reimbursed for absence of a sufficiently extensive description.

AOPA has taken the following actions as well: 1) initiated a portal where AOPA members can express their thoughts with respect to how the proposal could be improved; 2) has provided a summary and prewritten comment lettter for patients so they may understand how these proposals would impact their care and take action; 3) is convening its Officers and members of the AOPA Coding & Reimbursement Committee within two weeks to formulate and prioritize responses to the proposal; and (4) activating an easy mechanism at www.AOPAvotes.org for AOPA members to provide comments to the DME MACs on the proposal.

AOPA will be coordinating with the O&P Alliance, and other stakeholder interests to encourage movement toward the most reasonable possible result from the DME MAC proposed revisions to the proposed LCD and Policy Article.  The deadline for comments is August 31, 2015.  While AOPA has opened a website connection to make it easier for interested parties to respond to the proposal, those wishing to write directly to the DME MACs in response to the proposal should submit comments electronically to the DME MAC medical director at the e-mail address below no later than close of business on August 31, 2015 at DMAC_Draft_LCD_Comments@anthem.com, with “LCD Draft: Lower Limb Policy” in the subject line.

Take action now at www.AOPAvotes.org!