Obtaining a Medicare L-Code
JIM Marshall
Description
Collection
Title:
Obtaining a Medicare L-Code
Creator:
JIM Marshall
Date:
11/11/2009
Text:
Collier Rehabilitation Systems has been fabricating and delivering a novel prosthetic socket system to our patients for the past thirteen years known as the Variable Geometry Anterior-Posterior Socket(c) VGAP(c) or Patient Adjustable Socket System(c) PASS(c).
This socket system was developed by John G.Russell, CPO, FAAOP and involves a modification to a conventional socket to incorporate a moveable wall, typically the anterior wall for an AK socket and the posterior wall for a BK socket. This feature provides for the management of residual limb volume change under patient control via the incorporation of a SiDi adjustable strap and buckle. The moveable wall and adjustability provide for easier donning in the case of residual limb swelling or volume change and is especially effective for patients with a residual limb having a bulbous distal end. Additionally, the adjustability feature allows the patient to tighten or loosen the fit of their prosthetic limb to accomodate varying use conditions and fit by simply adjusting the ratchet buckle without the need to remove their clothing and their prosthetic limb to add or remove socks.
Since introduction of this socket system, we have been successful in billing and receiving reimbursement for this socket modification using the L5999 code from most of the major insurance companies. Medicare has never reimbursed us for this socket modification as there is no established L-code or pricing for this modification. Recently, a major insurer and HMO that we work with has changed their reimbursement policies and no longer will reimburse for L-codes that do not have an established Medicare price.
We are faced with two choices: stop billing for this socket modification and provide it free of charge to our patients, accepting a lower profit margin for our services or petition Medicare to obtain an L-code with an established price for this modification.
Does anyone have direct experience with the process of obtaining an L-code from Medicare for a modification to a prosthetic socket? I am interested in the timeframe required and the level of difficulty in obtaining Medicare approval.
Any constructive inputs would be greatly appreciated. For those who might be inclined to send a response along the lines of: good luck, dreamer or what have you been smoking, please save all of us alot of time and don't waste the keystrokes.
Jim Marshall, Owner
Collier Rehabilitation Systems
Pleasant Hill, CA
This socket system was developed by John G.Russell, CPO, FAAOP and involves a modification to a conventional socket to incorporate a moveable wall, typically the anterior wall for an AK socket and the posterior wall for a BK socket. This feature provides for the management of residual limb volume change under patient control via the incorporation of a SiDi adjustable strap and buckle. The moveable wall and adjustability provide for easier donning in the case of residual limb swelling or volume change and is especially effective for patients with a residual limb having a bulbous distal end. Additionally, the adjustability feature allows the patient to tighten or loosen the fit of their prosthetic limb to accomodate varying use conditions and fit by simply adjusting the ratchet buckle without the need to remove their clothing and their prosthetic limb to add or remove socks.
Since introduction of this socket system, we have been successful in billing and receiving reimbursement for this socket modification using the L5999 code from most of the major insurance companies. Medicare has never reimbursed us for this socket modification as there is no established L-code or pricing for this modification. Recently, a major insurer and HMO that we work with has changed their reimbursement policies and no longer will reimburse for L-codes that do not have an established Medicare price.
We are faced with two choices: stop billing for this socket modification and provide it free of charge to our patients, accepting a lower profit margin for our services or petition Medicare to obtain an L-code with an established price for this modification.
Does anyone have direct experience with the process of obtaining an L-code from Medicare for a modification to a prosthetic socket? I am interested in the timeframe required and the level of difficulty in obtaining Medicare approval.
Any constructive inputs would be greatly appreciated. For those who might be inclined to send a response along the lines of: good luck, dreamer or what have you been smoking, please save all of us alot of time and don't waste the keystrokes.
Jim Marshall, Owner
Collier Rehabilitation Systems
Pleasant Hill, CA
Citation
JIM Marshall, “Obtaining a Medicare L-Code,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 22, 2024, https://library.drfop.org/items/show/230928.
