Retired - Endoskeletal Prosthetic Knee-Shin Systems - Correct Coding

DME MAC and PDAC Joint Publication

The DME MACs want to remind DMEPOS suppliers which HCPCS L-Codes are available to fully describe the prosthetic knee-shin system incorporated into the prosthetic limb delivered to the beneficiary. This article addresses the range of L-codes appropriate for an endoskeletal lower limb claim submission.

Complete Endoskeletal Lower Extremity Prostheses

The endoskeletal prosthetic lower extremity codes (Group 1) include reimbursement for a molded prosthetic socket, an endoskeletal single axis knee-shin system and a SACH foot.

Group 1

Endoskeletal Knee-Shin Systems

The knee-shin systems found in Group 2 are considered an upgrade to the knee-shin system included in Group 1. The beneficiary may qualify for an upgraded knee-shin system found in Group 2. Qualification is dependent on medical documentation and assigned K-Level modifier (K0-K4). The Group 2 L-codes can fully describe a complete prosthetic knee-shin system commonly referred to as a “base knee code”. The use of two L-codes from Group 2 to fully describe the knee-shin system would be considered incorrect coding (unbundling).

Group 2

Additional Features and Functions

The Group 3 table includes a secondary list of L-codes which describe other features and functions not found in the Group 2 “base knee codes”.  These addition codes describe additional features and/or functions that do not describe a complete knee-shin system and must be used in combination with an L-code with a base knee-shin system. The use of Group 3 L-codes may also depend on the medical documentation and the assigned K-Level modifier (K0-K4).

Group 3

HCPCS code L5999 must not be used to bill for features or functions of the knee-shin system included in Group 1, Group 2 or Group 3 code lists. Use of HCPCS code L5999 in this manner will be considered incorrect coding (unbundling).

Suppliers are reminded to refer to the Lower Limb Prostheses LCD (L33787) for the appropriate K-Level modifier for each HCPCS code.

PDAC’s Product Classification List should be checked for the appropriate assigned L-codes for products billed to Medicare. Suppliers should also read the DME MAC publication, HCPCS CODING RECOMMENDATIONS FROM NON-MEDICARE SOURCES - CORRECT CODING, for guidance with coding products not found in the Product Classification List.

For questions about correct coding, contact the PDAC Contact Center at 877-735-1326 during the hours of 9:30 a.m. to 5:00 p.m. ET, Monday through Friday, or email the PDAC by completing the DME PDAC Contact Form located on the PDAC website.