DME MACs and PDAC Release Joint Publication Announcing Coding Verification Requirement for Six Lower Limb Prosthetic Codes that Will Require Medicare Prior Authorization


On June 26, 2020, the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) and Pricing, Data Analysis, and Coding Contractor (PDAC) released a joint announcement for a new coding verification requirement for the six lower limb prostheses that were previously announced as  subject to Medicare prior authorization. While implementation of Medicare prior authorization has been postponed due to the COVID-19 public health emergency, it is expected that the program will be implemented in the future.

The joint publication announced that, effective for claims with dates of service on or after January 1, 2021, the only products which may be billed using codes L5856, L5857, L5858, L5973, L5980, and L5987 are those for which a written Coding Verification Review has been made by the PDAC and is listed on the PDAC Product Classification List.

In addition to the joint DME MAC/PDAC publication announcing the coding verification requirement for the six prosthetic codes discussed above, the four DME MACs simultaneously released a revised version of the Lower Limb Prostheses Policy Article (PA) with an effective date of August 1, 2020.  The revised PA includes new coding guidelines for L5856, L5857, L5858, L5980, L5981 and L5987.  Coding guidelines for L5973 were published in a previous (January 2020) Policy Article revision.

AOPA’s Coding and Reimbursement Committee will be undertaking a comprehensive review of the Policy Article coding guideline revisions as well as the coding verification requirement and will engage in collaborative discussions with the PDAC and the DME MACs.

The joint publication announcing the coding verification requirement may be viewed here. And view the revised Lower Limb Prosthesis Policy Article here.

Questions may be directed to Joe McTernan at jmcternan@aopanet.org or Devon Bernard at dbernard@aopanet.org.