Billing for O&P devices and care is complicated. Count on “Got FAQs?” to help ensure you are using the most current information when preparing your claims. This month’s column answers your questions about codes for microprocessor knees, sovaldi workers’ compensation insurance, view and K-level modifiers.
question :
I have just provided my first C-Leg compact (Ottobock) and I am not sure how I should correctly code for this. I heard several providers at a recent meeting state that their claims have been audited when billing for microprocessor-knee systems. My patient is covered by Medicare.

Answer :
On December 15, 2011, Medicare issued a press release regarding correct coding and billing for microprocessor-controlled knee systems. The following are the only Healthcare Common Procedure Coding System (HCPCS) codes billable for a C-Leg compact or any similar microprocessor-controlled knee systems:

  • L-5828: addition, endoskeletal knee-shin system, single axis, fluid swing and stance phase control.
  • L-5845: addition, endoskeletal knee-shin system, stance flexion feature, adjustable.
  • L-5858: addition to lower-extremity prosthesis, endoskeletal knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type.

For any of these microprocessor-controlled knee systems, HCPCS code L-5930 (addition, endoskeletal system, high-activity knee control frame) may only be used with K-4 functional level patients. To view the CMS press release, visit www.oandp.com/link/132

question :
We are starting to receive more patients who have workers’ compensation insurance claims. I am not familiar with workers’ compensation rules and would like to be able to read information on this. I have searched the workers’ compensation website, and I am unable to find information on billing for O&P claims. We are located in Florida.

Answer :
For information about Florida workers’ compensation reimbursement policies, codes, guidelines, and payment methodologies to determine maximum reimbursement allowances, refer to the Florida Workers’ Compensation Health Care Provider Reimbursement Manual. Visit www.oandp.com/link/133 to access the manual.

question :
I am relatively new to billing for prosthetics. Is there any information I can find that would let me know what K-level modifier is allowed to be billed with a particular L-Code? I was told to use the K-3 modifier for the claim on a patient’s prosthetic foot, and I am not sure if I am using the correct L-Code for this.

Answer :
According to Medicare guidelines, a determination of the type of foot for the prosthesis will be made by the treating physician and/or the prosthetist based upon the functional needs of the patient.

An external keel SACH foot (L-5970) or single-axis ankle/foot (L-5974) is covered for patients whose functional level is 1 or above. A flexible-keel foot (L-5972) or multiaxial ankle/foot (L-5978) is covered for patients whose functional level is 2 or above. A microprocessor-controlled ankle-foot system (L-5973), energy-storing foot (L-5976), dynamic response foot with multiaxial ankle (L-5979), flex-foot system (L-5980), flex-walk system or equal (L-5981), or shank-foot system with vertical-loading pylon (L-5987) is covered for patients whose functional level is 3 or above.