Retired - Correct Coding and Billing for Microprocessor-Controlled Knee Systems

IMPORTANT: THIS DOCUMENT CONTAINS OUTDATED INFORMATION.

Content provided on this page contains outdated information and instruction and should not be considered current. PDAC is providing this archived information for research purposes only. This archived article contains previously issued instructions that have since been updated or no longer applicable for Medicare billing purposes.

Recent claim reviews note that suppliers are billing miscellaneous code L5999 (lower extremity prosthesis, not otherwise classified) for various elements of microprocessor-controlled knee systems such as the Otto Bock C-Leg®, C-Leg Compact™, or Genium™. This use of miscellaneous codes is not correct. For example, functions performed by the on-board microprocessors and/or sensors (e.g., "real-time gait assessment," "electronically controlled static stance regulator, adjustable"), or programming necessary for use, must not be billed using L5999. Use of additional codes is limited to those specified below. There is no separate billing and reimbursement for any other features or functions since the allowance for all functions and features is included in the payment for codes listed below.

Base code L5856

The following are the only HCPCS codes billable for C-Leg®, Genium™ or any similar microprocessor controlled knee systems:

• L5828 – addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
• L5845 – addition, endoskeletal knee-shin system, stance flexion feature, adjustable
• L5848 – addition to endoskeletal knee-shin system, fluid stance extension, dampening feature, with or without adjustability
• L5856 – addition to lower extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type

Base code L5858
The following are the only HCPCS codes billable for C-Leg Compact™ or any similar microprocessor controlled knee systems:

• L5828 – addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control
• L5845 – addition, endoskeletal knee-shin system, stance flexion feature, adjustable
• L5858 – addition to lower extremity prosthesis, endoskeletal knee shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type

For any of the above microprocessor controlled knee systems:

• HCPCS code L5930 (addition, endoskeletal system, high activity knee control frame) may only be used with K4 functional level patients.
• Do not bill separately at initial issue miscellaneous code L5999 for the pylon with sensor for use with microprocessor controlled knee systems. It is considered included in the payment for L5856 and L5858.

Additional information about coverage, coding and correct billing may be found in the supplier manual, local coverage determinations and on the Pricing, Data Analysis and Coding Contractor (PDAC) web site at www.dmepdac.com.