Coding for prosthetics

Prior to the invention of a coding system

- clinicians simply billed their own individual fees for their own individual services

- some insurance companies asked clinicians to "describe" what they did on a claim form

- No uniform method in O&P for billing and describing services and devices provided

AOPA and Blue Cross Blue Shield of South Carolina developed the first template of the L-code system in the _______

1970s

Centers for medicare and medicaid services (CMS)

- Adpoted South Carolina pilot system in 1978

- The Healthcare Common Procedure Coding System (HCPCS) was estabilisted to provide a standard coding system for describing specific items and services provided in healthcare delivery

HCPCS Comprised of ____ levels

2

Level 1

American medical association current procedural terminology (CPT)

Level 2

Identifies products, supplies, or services not included in CPT codes

- Durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS)

- Alpha-numeric coding (single alphabetical letter followed by 4 numeric digits

o L-Codes

What is an L-Code?

- Orthotic and prosthetic procedures and devices

- COnsists of base codes and add-on codes

- Fee for service

Base code

simplest possible procedure

Add-on code

can be applied if more complex care is required

Fee for service (FFS)

- we recieve a "single fee" for an item delivered, but that single fee pays for all services provided to the patient, not just the single delivery event

- encounters for evalvuation, measuring, fabrication, fitting and follow-up

Base code Example

L-5301 below knee, molded socket, shin, SACH foot, endoskletal system

"L"

identifies that the code is for an orthotic or prosthetic

"numbers"

define what body aprt and type of orthosis/prosthesis

Add-on codes

-describes additional features or services provided

- Ex: knees, feet, soft goods, socket design, suspension

- Can be K-level dependent

- Requires justification

K-Levels

K0 - does not warrant a prosthesis

K1 - household ambulator

K2 - limited community ambulator

K3 - community ambulator (variable cadence)

k4 - high impact, stress or energy levels

K Level Zero

The patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility

K level One

The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. This is typical of a household ambulator or a person who only walks about in their own home.

K Level two

the patient has the ability or potential for ambulation with the ability to traverse lowlevel environmental barriers such as curbs, stairs or uneven surfaces

K level three

the patient has the ability or potential for ambulation with variable cadence. A person at level 3, is typically a community ambulator who also has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic use beyond simple locomotion

K level four

the apatient has the ability or potential for prosterosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels. This is typical of the prosthetic demands of the child, active adult or athlete

What is required to bill

All DMEPOS items require a written/prescription from a treating practitioner that documents the need for a beneficiary to be provided an item (Standard Written Order, SWO_

Who writes an SWO

physician, physician assistant, nurse practitioner, clinical nurse specialist

SWO must contain

- beneficiary name or medicare beneficiary identifier

- general descritption of the item

o general description, brand name, HCPCS code, or HCPCS narrative

o Equipment - accessories, additional features that need an upgraded code

o Supplies - concurrently ordered supplies

- quantity to be dispennsed

- order date

- treating practitioner name

- Treating pracitioner signature

DMEPOS fee schedule

Durable medical equipment, prosthetics/orthotics and supplies

- complete listing of fees used by Medicare to reimburse a supplier for an item or service

International classification of disease coding (ICD-10)

- Standard transaction code set for diagnostic purposes under HIPAA

- used to document diagnoses but also affects payment

Transtibial ICD-10 codes - Acquired absence of leg below knee

o Z89.511 (right)

o Z89.512 (left)

Transtibial ICD-10 codes - complete traumatic amputation at level between knee and ankle

- S88.111 (right)

- S88.112 (left)

- A - initial (trauma)

- D - subsequent (revision)

- S - sequela