RE Region A Medicare/Prosthetics

RE Region A Medicare/Prosthetics

David Loney, CP

3/10/2014

Thanks very much to all who responded. Some misunderstood and thought the question was a simply to justify using acrylic socket and total contact. The issue is actually how the entire L-code system works and evidence of how/why we’re allowed to bill add-on codes to a base code when billing for a prosthesis. I tried to attach 4 files to this, but the list serv wouldn’t let the email go through. 3 of the files are papers on total contact, and one is an old article from In-Motion that I found regarding the L-code system. The best resources I found for total contact and similar add-on codes are articles in the O&P Virtual Library found through OandP.com and the Atlas of Limb Prosthetics.

If anyone does come up with any other articles regarding the L-code system, history, development, etc, we would greatly appreciate you sharing it.

Thank you,
Georgia Loney
WillowBrook P&O

See responses below the original note.

ORIGINAL NOTE:
We are being told that the current Medical Director for Region A believes that we are “unbundling” when we bill several codes to describe a prosthesis, that all of these addition codes are included in the base code. The most recent ongoing dispute is regarding billing both acrylic and total contact. Here is the question we received today: “Is it possible for you to obtain any clinical articles, whitepapers. Etc… regarding billing the both of the additions or any additional information to substantiate the need for both the acrylic and total contact additions?”
If anyone has any articles, papers, etc, related to this issue, would you please forward them to me? I will copy all of these onto the listserv so everyone has the info, as I know we will not be the only prosthetic facility affected.

RESPONSES:
I would approach this with regard to the difference between a preparatory and definitive socket. Because they cannot be billed for as a preparatory, thus, they are not bundled. Remember that USA cannot be billed for a preparatory, ultralight, suction, acrylic. My viewpoint is that suction is there because the preparatory limb shrinks so much so quickly, that it cannot be billed. The acrylic because this is used for long-term strength, and thus, since the preparatory is only designed for 6 months to 1.5 years, this is not appropriate. The ultralight I have a few ideas on, but nothing as solid as the two mentioned above.

try digital resource foundation on the o and p .com experience with total contact prosthesis.

They are asking for a paper that compares apples to oranges! Acrylic is the material, and Total Contact is the design principle. We know that this combo gives superior results, but they really have nothing to do with each other. The tone of the request suggests that the codes are mutually exclusive, when in fact we might consider them to be individually exclusive.
At one time there was a paragraph in the intro to the codes that described the base/add-on system. Maybe that will help, if it still exists.

This article does speak to total contact design.
<URL Redacted>

I don't have any articles, but just a piece of advice. I would begin the letter with a simple definition of both terms so that the auditor knows these are 2 entirely different things. Billing code LXXXX (acrylic code) as described by Medicare states XXXXX. This refers to the type of material used....and in this case was carbon fiber. This material is more expensive than the standard materials used and is very difficult to work with. Adding this material increases the time to laminate and produce the socket and increases the time to cut and trim it because of the carbon fiber addition. The actual material costs of the laminated socket with carbon fiber are also increased. Then do the same thing for the total contact code.

Below are what we use for justifications as well the reference we based them on and the excerpt from the reference. Quality Outcomes ( <Email Address Redacted> ) offers over 100 LE Prx justifications with the same format as the 2 I'm providing below...
L5629, ADDITION TO LOWER EXTREMITY, BELOW KNEE, ACRYLIC SOCKET.
Reference: Berry, Dale A. CP(C)(1987). Composite Materials for Orthotics and Prosthetics. Orthotics and Prosthetics, Vol. 40, No. 4, pp. 35-43.
Excerpt: Acrylic resins are a lightweight thermosetting plastic with excellent wetting properties and good inherent strength, making thin ultra-light orthopedic appliances possible.
Justification: An acrylic laminated socket is medically necessary for providing a thin, ultra-light socket while maintaining good inherent strength.
L5637, ADDITION TO LOWER EXTREMITY, BELOW KNEE, TOTAL CONTACT.
Reference: ICRC Course Work Manual. Transtibial Prosthetics. 2007.
Excerpt: From a biomechanical standpoint, the total contact design is generally preferable because it offers the following advantages: 1. It helps to prevent edema and aids venous return. . 2. The total contact socket provides greater area over which to distribute the load. Even though the load supported by the end of a mid-leg or mid-thigh stump is not great, it does decrease to some extent the load that must be borne by the other areas of the stump. 3. Because it is in contact with a greater area of the stump, the total contact socket provides better sensory feedback to the wearer.
Justification: Medically necessary to reduce skin shear, excessive limb pressure, and edema. A total contact socket helps distribute the ground reaction force throughout the residual limb to reduce high pressure areas, reduces edema, increases proprioception, and increases venous return.

The description I found in the PDAC for example for L5321 is as follow:
ABOVE KNEE, MOLDED SOCKET, OPEN END, SACH FOOT, ENDOSKELETAL SYSTEM, SINGLE AXIS KNEE .
To suggest that total contact is part of the base code when the base code says OPEN END is nuts.
I can't imagine you will find any articles that justify billing both codes together. The arguments that could be made to justify each of these codes are not at all related.