Retired - Appropriate Coding and Billing of Lower Limb Prosthetic Covers and Covering Systems

The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have received a high volume of submitted claims for lower limb prosthetic covers (L5704-L5707) and protective covering systems (L5962, L5964, and L5966) for the same lower limb prosthesis. The need for both of these is rare, and this article is intended to educate suppliers and providers about the occasions where both of these are considered to be reasonable and necessary.

Lower limb prosthetic covers (L5704–L5707) 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 prosthetics.

Protective outer surface covering systems (L5962, L5964, and L5966) 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 L5704-L5707. 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 L5704–L5707 and is rarely necessary.

Documentation to support medical necessity of a protective outer surface covering system (L5962, L5964, and L5966) must indicate the type of extraordinary activities that would justify the need for extra protection afforded by this highly durable item. Again, this type of extra protection is not routinely necessary.

When billing for the protective outer surface covering systems (L5962, L5964 and L5966), 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.

Suppliers should utilize the Medicare Pricing, Data Analysis and Coding Contractor (PDAC) website to ensure accurate coding of DMEPOS claims.