Prosthetic Knee Billing Issue
Richenda Janowitz
Description
Collection
Title:
Prosthetic Knee Billing Issue
Creator:
Richenda Janowitz
Date:
12/17/2021
Text:
Good afternoon ListServ,
DAW Industries currently makes a Prosthetic knee called the Sure Stance
Knee. The suggested L-Codes for K3 are L5816, L5840, L5845, L5848, and
L5850.
The problem is, neither Medicare nor Medicaid support the billing of L5816
and L5840 together.
CMS Policy Article A52496 states:
Addition codes for endoskeletal knee-shin systems are L5610, L5611, L5613,
L5616, L5810, L5811, L5812, L5814, *L5816*, L5818, L5822, L5824, L5826,
L5828, L5830, *L5840* are considered an upgrade to the knee-shin system.
The beneficiary may qualify for an upgraded knee-shin system based on their
assigned K-Level modifier (K0-K4), as referenced in the LCD. These HCPCS
codes can fully describe a complete prosthetic knee-shin system commonly
referred to as a “base knee code”. A single addition code can fully
describe a complete knee-shin system and thus the use of two codes (L5610,
L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822,
L5824, L5826, L5828, L5830, L5840) would be considered incorrect coding
(unbundling).
The data.medicaid.gov dataset for NCCI edits shows (column 1) L5840 and
(column 2) L5816 as being denied as mutually exclusive procedures, with a
modifier indicator of one, meaning there may be a way to bypass this edit,
but I have no idea what it is.
DAW has advised us to use their Letter of Medical Necessity to explain the
coding choice for this particular knee. So far, it hasn't worked for us.
According to DAW we're the only Sure Stance purchaser who has had this
billing issue. Has anyone else encountered this or successfully billed
these two codes together?
Thank you,
Richenda Janowitz, Claims and Accounts Specialist
Antelope Valley Orthotics & Prosthetics
DAW Industries currently makes a Prosthetic knee called the Sure Stance
Knee. The suggested L-Codes for K3 are L5816, L5840, L5845, L5848, and
L5850.
The problem is, neither Medicare nor Medicaid support the billing of L5816
and L5840 together.
CMS Policy Article A52496 states:
Addition codes for endoskeletal knee-shin systems are L5610, L5611, L5613,
L5616, L5810, L5811, L5812, L5814, *L5816*, L5818, L5822, L5824, L5826,
L5828, L5830, *L5840* are considered an upgrade to the knee-shin system.
The beneficiary may qualify for an upgraded knee-shin system based on their
assigned K-Level modifier (K0-K4), as referenced in the LCD. These HCPCS
codes can fully describe a complete prosthetic knee-shin system commonly
referred to as a “base knee code”. A single addition code can fully
describe a complete knee-shin system and thus the use of two codes (L5610,
L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822,
L5824, L5826, L5828, L5830, L5840) would be considered incorrect coding
(unbundling).
The data.medicaid.gov dataset for NCCI edits shows (column 1) L5840 and
(column 2) L5816 as being denied as mutually exclusive procedures, with a
modifier indicator of one, meaning there may be a way to bypass this edit,
but I have no idea what it is.
DAW has advised us to use their Letter of Medical Necessity to explain the
coding choice for this particular knee. So far, it hasn't worked for us.
According to DAW we're the only Sure Stance purchaser who has had this
billing issue. Has anyone else encountered this or successfully billed
these two codes together?
Thank you,
Richenda Janowitz, Claims and Accounts Specialist
Antelope Valley Orthotics & Prosthetics
Citation
Richenda Janowitz, “Prosthetic Knee Billing Issue,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/255806.
