Lower Limb Prostheses - Policy Article - Effective October 2015

Revision Effective Date: 08/01/2026
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Removed: K-level modifier information that pertained to claims submitted for knee, foot, ankle, and hip HCPCS codes
Revised: “This expectation of functional ability information must be clearly documented and retained in the prosthetist's records.” to “Functional ability information must be clearly documented and retained in the prosthetist's records.,” as clarification
Revised: “The simple entry of a K modifier in those records is not sufficient.” to “The simple entry of a K-level modifier in those records is not sufficient.,” as clarification
MODIFIERS:
Revised: “GA, GY, GZ, KX, LT, and RT MODIFIERS:” to “GA, GY, GZ, K0, K1, K2, K3, K4, KX, LT, and RT MODIFIERS:”
Added: “K-level modifiers are K0, K1, K2, K3, and K4. These modifiers are used to indicate the expected beneficiary functional level. Information to support the K-level modifier must be retained in the supplier’s files and available to the DME MAC upon request.,” as clarification
Added: K-level modifier information that pertains to claims submitted for knee, foot, ankle, and hip HCPCS codes (relocated from the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS section)
Added: L5827 to the HCPCS codes that must be submitted with a K-level modifier, as clarification
Added: L5845, L5850, L5855, L5925, L5926, L5968, and L5988 as HCPCS codes that must be submitted with a K-level modifier (as of dates of service on or after 08/01/2026)
Added: “Claim lines billed for these lower limb prosthetic HCPCS codes without a K-level modifier will be rejected as missing information.,” as clarification
CODING GUIDELINES:
Revised: “Codes L5940, L5950, and L5960 for ultra-light materials may only be used when materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis.” to “Codes L5940, L5950, and L5960 for ultra-light materials may only be used when materials such as carbon fiber, fiberglass, Kevlar, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis (i.e., L5301, L5312, L5321, L5331, L5341, L5700, L5701, L5702, or L5703).,” as clarification
Revised: “microprocessor controlled knee” to “microprocessor-controlled knee”
Revised: "K-Level modifier” to “K-level modifier”
Revised: “Included features in the code are described by L5845 and L5848.” to “Features included in the code are described by L5845 and L5848.”
Revised: “The use of these codes can be used to fully describe additional features or functions not found in the prosthetic foot system (L5969, L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979 L5980, L5981 and L5987).” to “These codes can be used to fully describe additional features or functions not found in the prosthetic foot system (L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987).,” as clarification
Revised: “Use of L5968, L5982, L5984 or L5986 is based on the beneficiary’s K-level modifier (K0-K4), as referenced in the LCD.” to “Use of L5982, L5984, L5985, or L5986 is based on the beneficiary’s K-level modifier (K0-K4), as referenced in the LCD.,” as clarification
Revised: “L5968, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987.” to “L5968, L5969, L5982, L5984, L5985, L5986, L5988, L5990 are additional features and/or functions that do not describe a complete prosthetic foot and may be used in combination with L5970, L5971, L5972, L5973, L5974, L5975, L5976, L5978, L5979, L5980, L5981, and L5987.,” as clarification
Revised: “microprocessor controlled foot” to “microprocessor-controlled foot”
Revised: “There is no separate payment for batteries (L7360, L7364, and L7367) and/or battery chargers (L7362, L7366, and L7368) billed concurrently with a powered base item.” to “There is no separate payment for batteries (L7360, L7364, and L7367) and/or battery chargers (L7362, L7366, and L7368) billed concurrently with a powered base item (L5781, L5782, L5856, L5857, L5858, L5859, and L5973).,” as clarification
Revised: The format of the table that pertains to items in Column II which are included in the payment for each Column I code, as clarification
06/18/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2026
CODING GUIDELINES:
Added: Coding guideline information for L5910, L5920, L5629, L5631, L5649, L5643, L5645, L5651, L5637, and L5650, as clarification
Revised: “For codes L5940, L5950, and L5960, the unit of service is per limb.” to “The unit of service for codes L5940, L5950, and L5960 is one per limb.” in the coding guideline information for L5940, L5950, and L5960, as clarification
Added: “The unit of service is one per limb.” to the coding guideline information for L5783, as clarification
Added: Coding guideline information for L5992


04/09/2026: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 10/01/2025
CODING GUIDELINES:
Added: HCPCS code L5657 coding guideline information
Added: “HCPCS code may include the lamination kit.” to HCPCS code L5783 coding guideline information
10/23/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2025
CODING GUIDELINES:
Added: “Prosthetic devices (such as sockets, inserts, and applicable additions [e.g., light weight material]) that are custom fabricated for the individual beneficiary are not solely restricted to standard methods of fabrication (e.g., wet lamination and prepreg composite) and can include alternative fabrication methods (e.g., additive manufacturing). Correct coding of custom fabricated items includes compliance with the HCPCS long description of the individual HCPCS code, along with any other published coding guidelines.” as clarification


09/18/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2025
CODING GUIDELINES:
Revised: Coding guidelines for HCPCS codes L5671 and L5647, as clarification
Removed: Coding guideline for the Infinite Socket, as clarification
Revised: “Addition codes for endoskeletal knee-shin systems (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, and L5841) are considered an upgrade to the knee-shin system.” to “Addition codes for endoskeletal knee-shin systems (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, and L5841) are considered an upgrade to the knee-shin system.”
Revised: “A single addition code can fully describe a complete knee-shin system and thus the use of two codes (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, and L5841) would be considered incorrect coding (unbundling).” to “A single addition code can fully describe a complete knee-shin system and thus the use of two codes (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, and L5841) would be considered incorrect coding (unbundling).”
Revised: “L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, and L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, and L5841).” to “L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, and L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5827, L5828, L5830, L5840, and L5841).”
Added: Coding guideline for HCPCS code L5827
04/03/2025: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 09/01/2024
FUNCTIONAL LEVEL CHARACTERISTICS:
Added: Section header and functional level characteristics information
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Information which specifies that orthotist and prosthetist records are considered part of the medical record to support documentation created by the treating practitioner
Added: L5615 and L5841 to the HCPCS codes referenced in regard to claims for knee, foot, ankle, and hip components
Added: Information that must be included in the medical records for certain HCPCS codes (L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5856, L5857, L5858) for beneficiaries whose functional level is 2
MODIFIERS:
Revised “LT and RT MODIFIERS:” to “GA, GY, GZ, KX, LT, and RT MODIFIERS:”
Added: Information which pertains to inclusion of the KX, GA, GY, or GZ modifier on claims
Added: GY modifier usage when billing for a prosthetic donning sleeve (L7600)
Removed: “(refer to the CODING GUIDELINES section for additional information)” in regard to RT and LT modifiers
Added: RT and LT modifier information (relocated from the CODING GUIDELINES section)
CODING GUIDELINES:
Revised: The layout and content located within “PROSTHETIC SYSTEMS,” including addition of “Immediate Post Op” with relevant information, “Preparatory” with relevant information, “Initial” with relevant information, “Exoskeletal” with relevant information, and “Endoskeletal” with relevant information
Added: “Prosthetic system codes should not be used when billing a replacement socket for an existing prosthesis.”
Removed: “L5301, L5540, L5321, L5590 should not be used when billing a replacement socket for an existing prosthesis.”
Removed: “The use of L5301, L5540, L5321, L5590 with a replacement socket is incorrect coding (unbundling).”
Added: “Replacements” with relevant information
Added: “The use of the prosthetic system codes with a replacement socket is incorrect coding (unbundling).”
Revised: “The beneficiary may qualify for an upgraded knee-shin system depending on their assigned K-level modifier (K0-K4), as referenced in the LCD.” to “The beneficiary may qualify for an upgraded knee-shin system depending on their assigned K-level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Revised: HCPCS codes referenced as addition codes for endoskeletal knee-shin systems that are considered an upgrade to the knee-shin system, to include L5615 and L5841
Revised: “The beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4), as referenced in the LCD.” to “The beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Revised: HCPCS codes referenced as single addition codes that can fully describe complete knee-shin systems and for which the use of two codes would be considered incorrect coding, to include L5615 and L5841
Revised: “L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840).” to “L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, and L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, and L5841).”
Revised “The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4), as referenced in the LCD.” and “The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD.” to “The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Revised: “The beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) as referenced in the LCD.” to “The beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Removed: RT and LT modifier information
07/18/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 09/01/2024
FUNCTIONAL LEVEL CHARACTERISTICS:
Added: Section header and functional level characteristics information
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Information which specifies that orthotist and prosthetist records are considered part of the medical record to support documentation created by the treating practitioner
Added: L5615 and L5841 to the HCPCS codes referenced in regard to claims for knee, foot, ankle, and hip components
Added: Information that must be included in the medical records for certain HCPCS codes (L5610, L5613, L5614, L5615, L5722, L5724, L5726, L5728, L5780, L5814, L5822, L5824, L5826, L5828, L5830, L5840, L5841, L5848, L5856, L5857, L5858) for beneficiaries whose functional level is 2
MODIFIERS:
Revised “LT and RT MODIFIERS:” to “GA, GY, GZ, KX, LT, and RT MODIFIERS:”
Added: Information which pertains to inclusion of the KX, GA, GY, or GZ modifier on claims
Added: GY modifier usage when billing for a prosthetic donning sleeve (L7600)
Removed: “(refer to the CODING GUIDELINES section for additional information)” in regard to RT and LT modifiers
Added: RT and LT modifier information (relocated from the CODING GUIDELINES section)
CODING GUIDELINES:
Revised: The layout and content located within “PROSTHETIC SYSTEMS,” including addition of “Immediate Post Op” with relevant information, “Preparatory” with relevant information, “Initial” with relevant information, “Exoskeletal” with relevant information, and “Endoskeletal” with relevant information
Added: “Prosthetic system codes should not be used when billing a replacement socket for an existing prosthesis.”
Removed: “L5301, L5540, L5321, L5590 should not be used when billing a replacement socket for an existing prosthesis.”
Removed: “The use of L5301, L5540, L5321, L5590 with a replacement socket is incorrect coding (unbundling).”
Added: “Replacements” with relevant information
Added: “The use of the prosthetic system codes with a replacement socket is incorrect coding (unbundling).”
Revised: “The beneficiary may qualify for an upgraded knee-shin system depending on their assigned K-level modifier (K0-K4), as referenced in the LCD.” to “The beneficiary may qualify for an upgraded knee-shin system depending on their assigned K-level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Revised: HCPCS codes referenced as addition codes for endoskeletal knee-shin systems that are considered an upgrade to the knee-shin system, to include L5615 and L5841
Revised: “The beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4), as referenced in the LCD.” to “The beneficiary may qualify for an upgraded knee-shin system based on their assigned K-Level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Revised: HCPCS codes referenced as single addition codes that can fully describe complete knee-shin systems and for which the use of two codes would be considered incorrect coding, to include L5615 and L5841
Revised: “L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840).” to “L5925, L5930, L5845, L5848, L5850, L5856, L5857, L5858, and L5859 are additional features and/or functions that do not describe a complete endoskeletal knee-shin system and must be used in combination with an L-code for a knee-shin system (L5610, L5611, L5613, L5615, L5616, L5810, L5811, L5812, L5814, L5816, L5818, L5822, L5824, L5826, L5828, L5830, L5840, and L5841).”
Revised “The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4), as referenced in the LCD.” and “The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) as referenced in the LCD.” to “The use of additional feature L-codes may also depend on the assigned K-Level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Revised: “The beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) as referenced in the LCD.” to “The beneficiary may qualify for an upgraded prosthetic foot based on their assigned K-level modifier (K0-K4) and any additional coverage criteria that must be met, as referenced in the LCD.”
Removed: RT and LT modifier information
07/18/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2024
CODING GUIDELINES:
Added: HCPCS code L5783 coding guideline information
05/02/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 04/01/2024
CODING GUIDELINES:
Added: HCPCS code L5783 coding guideline information
05/02/2024: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2024
CODING GUIDELINES:
Added: HCPCS code L5926 coding guideline information
12/28/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2024
CODING GUIDELINES:
Added: HCPCS code L5926 coding guideline information
12/28/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 10/01/2023
CODING GUIDELINES:
Added: “PROSTHETIC CONNECTORS”
Added: HCPCS code L5991 coding guideline information
Added: “L5614” to the HCPCS codes listed in reference to addition codes for exoskeletal knee-shin systems
Added: HCPCS code L5845 coding guideline information
Added: HCPCS code L5848 coding guideline information
Revised: HCPCS code L5982 coding guideline information, to include “Motion of this product is separate from any similar incidental prosthetic foot/ankle motions."
Revised: HCPCS code L5984 coding guideline information, to include “Motion of this product is separate from any similar incidental prosthetic foot/ankle motions."
12/14/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 10/01/2023
CODING GUIDELINES:
Added: “PROSTHETIC CONNECTORS”
Added: HCPCS code L5991 coding guideline information
Added: “L5614” to the HCPCS codes listed in reference to addition codes for exoskeletal knee-shin systems
Added: HCPCS code L5845 coding guideline information
Added: HCPCS code L5848 coding guideline information
Revised: HCPCS code L5982 coding guideline information, to include “Motion of this product is separate from any similar incidental prosthetic foot/ankle motions."
Revised: HCPCS code L5984 coding guideline information, to include “Motion of this product is separate from any similar incidental prosthetic foot/ankle motions."
12/14/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/21/2023
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Language pertaining to payment of a prosthesis when provided in a Part A covered hospital stay and Part A covered skilled nursing facility (SNF) stay
Added: “The prosthesis is reasonable and necessary for a beneficiary’s use during the Medicare Part A covered SNF stay” as a criterion for payment of a prosthesis delivered to a beneficiary during a Part A covered SNF stay when eligible for DME MAC coverage and payment
Added: “The prosthetic components are classified as major category III codes under the SNFs consolidated billing” as a criterion for payment of a prosthesis delivered to a beneficiary during a Part A covered SNF stay when eligible for DME MAC coverage and payment


01/26/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/21/2023
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Language pertaining to payment of a prosthesis when provided in a Part A covered hospital stay and Part A covered skilled nursing facility (SNF) stay
Added: “The prosthesis is reasonable and necessary for a beneficiary’s use during the Medicare Part A covered SNF stay” as a criterion for payment of a prosthesis delivered to a beneficiary during a Part A covered SNF stay when eligible for DME MAC coverage and payment
Added: “The prosthetic components are classified as major category III codes under the SNFs consolidated billing” as a criterion for payment of a prosthesis delivered to a beneficiary during a Part A covered SNF stay when eligible for DME MAC coverage and payment


01/26/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “beneficiary to be eligible” to “beneficiary’s lower limb prosthesis to be eligible” in regard to eligibility for reimbursement
CONTINUED MEDICAL NEED:
Added: Section header and continued medical need language
MODIFIERS:
Added: Section Header and “RT and LT MODIFIERS:”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
Added: L5781, L5782, L5985, L5988, L5000, L5010, and L5020 coding guidelines
Revised: “ANKLES” to “ANKLE AND LOWER EXTREMITY MOTION UNITS”
Revised: Statement pertaining to products that provide single motion or combination of motions, to include HCPCS codes L5985 and L5988 and to note “functional movement of lower limb during ambulation”
Added: “manufactured by R.G. Rincoe & Associates, Inc.” to L5968 coding guideline predicate product information
Added: “PARTIAL FOOT AND TOE FILLER INSERTS”
Removed: “MODIFIERS”
CODING VERIFICATION REVIEW:
Revised: Location of coding verification review information


05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: “beneficiary to be eligible” to “beneficiary’s lower limb prosthesis to be eligible” in regard to eligibility for reimbursement
CONTINUED MEDICAL NEED:
Added: Section header and continued medical need language
MODIFIERS:
Added: Section Header and “RT and LT MODIFIERS:”
Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
Added: L5781, L5782, L5985, L5988, L5000, L5010, and L5020 coding guidelines
Revised: “ANKLES” to “ANKLE AND LOWER EXTREMITY MOTION UNITS”
Revised: Statement pertaining to products that provide single motion or combination of motions, to include HCPCS codes L5985 and L5988 and to note “functional movement of lower limb during ambulation”
Added: “manufactured by R.G. Rincoe & Associates, Inc.” to L5968 coding guideline predicate product information
Added: “PARTIAL FOOT AND TOE FILLER INSERTS”
Removed: “MODIFIERS”
CODING VERIFICATION REVIEW:
Revised: Location of coding verification review information


05/26/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 FED. REG VOL 217):
Removed: “The link will be located here once it is available.”
Added: “The required Face-to-Face Encounter and Written Order Prior to Delivery List is available here.” with a hyperlink to the list


04/14/2022: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
CODING GUIDELINES:
Removed: Trademark symbols
Removed: “etc.” from the not all-inclusive list of other components of a prosthesis
Revised: Infinite Socket TT-S information, to include addition HCPCS code L5637
Revised: Coding guidelines for HCPCS codes L5968 and L5986
CODING VERIFICATION REVIEW:
Added: “(PCL)” after reference to “Product Classification List”
Added: Incorrect coding denial language for products billed using HCPCS that require written coding verification review
03/18/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
CODING GUIDELINES:
Removed: Trademark symbols
Removed: “etc.” from the not all-inclusive list of other components of a prosthesis
Revised: Infinite Socket TT-S information, to include addition HCPCS code L5637
Revised: Coding guidelines for HCPCS codes L5968 and L5986
CODING VERIFICATION REVIEW:
Added: “(PCL)” after reference to “Product Classification List”
Added: Incorrect coding denial language for products billed using HCPCS that require written coding verification review
03/18/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
CODING GUIDELINES:
Added: Coding guidelines for HCPCS codes L5856, L5857, L5858, L5980, L5981, and L5987
CODING VERIFICATION REVIEW:
Added: Section header for information related to PDAC coding verification review
Revised: PDAC coding verification review information for HCPCS code L5969, to include effective for DOS on or after 01/01/2014
Added: PDAC coding verification review information for HCPCS codes L5856, L5857, L5858, L5973, L5980, and L5987, effective for DOS on or after 01/01/2021
06/25/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 08/01/2020
CODING GUIDELINES:
Added: Coding guidelines for HCPCS codes L5856, L5857, L5858, L5980, L5981, and L5987
CODING VERIFICATION REVIEW:
Added: Section header for information related to PDAC coding verification review
Revised: PDAC coding verification review information for HCPCS code L5969, to include effective for DOS on or after 01/01/2014
Added: PDAC coding verification review information for HCPCS codes L5856, L5857, L5858, L5973, L5980, and L5987, effective for DOS on or after 01/01/2021
06/25/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Format of HCPCS codes referenced, from code ‘spans’ to individually-listed HCPCS
Revised: “physician’s” to “treating practitioner's”
Revised: “physician” to “practitioner”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIRMENTS:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: “ordering physician” to “treating practitioner”
Revised: “physician’s” to “treating practitioner’s”
CODING GUIDELINES:
Revised: Section to include sub-headers for organization of coding guidelines and related information
Added: Information related to prosthetic systems, sockets, and Infinite Socket information
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Added: Coding guidelines and related information for Knees, Ankles, Feet, and Microprocessor Ankle Foot Systems
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

03/12/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Revised: Format of HCPCS codes referenced, from code ‘spans’ to individually-listed HCPCS
Revised: “physician’s” to “treating practitioner's”
Revised: “physician” to “practitioner”
REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO FINAL RULE 1713 (84 Fed. Reg Vol 217):
Added: Section and related information based on Final Rule 1713
POLICY SPECIFIC DOCUMENTATION REQUIRMENTS:
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Revised: “ordering physician” to “treating practitioner”
Revised: “physician’s” to “treating practitioner’s”
CODING GUIDELINES:
Revised: Section to include sub-headers for organization of coding guidelines and related information
Added: Information related to prosthetic systems, sockets, and Infinite Socket information
Revised: Format of HCPCS code references, from code ‘spans’ to individually-listed HCPCS
Added: Coding guidelines and related information for Knees, Ankles, Feet, and Microprocessor Ankle Foot Systems
ICD-10 CODES THAT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Covered” updated to “ICD-10 Codes that Support Medical Necessity”
ICD-10 CODES THAT DO NOT SUPPORT MEDICAL NECESSITY:
Revised: Section header “ICD-10 Codes that are Not Covered” updated to “ICD-10 Codes that DO NOT Support Medical Necessity”

03/12/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/01/2019
CODING GUIDELINES:
Removed: L8505 from list of batteries billed concurrently with powered base, due to technical correction
Removed: L8505 from Column II of rebundling table, due to technical correction

02/21/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/01/2019
CODING GUIDELINES:
Removed: L8505 from list of batteries billed concurrently with powered base, due to technical correction
Removed: L8505 from Column II of rebundling table, due to technical correction

02/21/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/01/2019
CODING GUIDELINES:
Revised: RT and LT modifier billing instructions


02/07/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 03/01/2019
CODING GUIDELINES:
Revised: RT and LT modifier billing instructions


02/07/2019: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2018
CODING GUIDELINES:
Revised: "liner" to "insert" for continuity of terms
Added: Coding guidelines for prosthetic covers (L5704-L5707) and Protective outer surface covering systems (L5962, L5964, and L5966)
Added: Bundling table for Coding Batteries and Chargers Concurrently With a Powered Base Item


 04/12/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2018
CODING GUIDELINES:
Revised: "liner" to "insert" for continuity of terms
Added: Coding guidelines for prosthetic covers (L5704-L5707) and Protective outer surface covering systems (L5962, L5964, and L5966)
Added: Bundling table for Coding Batteries and Chargers Concurrently With a Powered Base Item


 04/12/2018: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2018


CODING GUIDELINES:


Added: Coding guidelines and bundling information for L7700


12/21/2017: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2018


CODING GUIDELINES:


Added: Coding guidelines and bundling information for L7700


12/21/2017: At this time 21st Century Cures Act applies to new and revised LCDs that restrict coverage, which require comment and notice. This revision is to an article that is not a local coverage determination.

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Updated: codes included in SNF payment due to clerical error
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifier instructions and Repair/Replacement language
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Revision Effective Date: 01/01/2017
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
Updated: codes included in SNF payment due to clerical error
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
Added: Modifier instructions and Repair/Replacement language
RELATED LOCAL COVERAGE DOCUMENTS:
Added: LCD-related Standard Documentation Requirements Language Article

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.

Effective July 1, 2016 oversight for DME MAC Articles is the responsibility of CGS Administrators, LLC 18003 and 17013 and Noridian Healthcare Solutions, LLC 19003 and 16013. No other changes have been made to the Articles.