Jurisdiction C DME MAC Announces Pre-Payment Review of Microprocessor Knee Code

On May 4, 2017, CGS Administrators, LLC, the Durable Medical Equipment Medicare Administrative Contractor (DME MAC) for Jurisdiction C, announced the initiation of a widespread pre-payment review for HCPCS code L5856-Addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type.  L5856 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 pre-payment review will begin on or around June 15, 2017 and suggested that providers review the current LCD and Policy Article for lower limb prostheses and to reference the CGS documentation checklist for lower limb prostheses that may be accessed here.

While the CGS documentation checklist is a useful tool, it does not contain any specific information regarding coverage requirements for microprocessor controlled prostheses.  AOPA members are encouraged to work with their physician partners to ensure that documentation regarding the need for a microprocessor controlled prosthetic knee is present in the patient’s medical record.  The documentation must address the need for a microprocessor knee over a conventional prosthetic knee as well as support the need for K3 or higher functional level components.

CGS did not indicate how many claims will be affected by the widespread review but did indicate that the pre-payment review will occur across all provider groups who submit claims including L5856.

AOPA will follow this issue very closely and provide continued support to AOPA members regarding this newly announced pre-payment review.  Questions regarding this issue may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.