Medicare administrative contractor announces prepayment review of microprocessor knee code

CGS Administrators LLC, the durable medical equipment Medicare administrative contractor for jurisdiction C, has announced a widespread prepayment review for a Healthcare Common Procedure Coding System code used for microprocessor knees and other devices, according to the American Orthotic and Prosthetic Association.

The review, scheduled to begin on or around June 15, targets Healthcare Common Procedure Coding System (HCPCS) code L5856, which covers additions to lower extremity prostheses, endoskeletal knee-shin systems, microprocessor control features, swing and stance phases, and electronic sensors of any type. According to the American Orthotic and Prosthetic Association (AOPA), L5856 is used as an addition code to prosthetic knee components that use a microprocessor to control the knee during both swing and stance phases of the gait cycle.

CGS has recommended providers review the current LCD and policy article for lower limb prostheses, and to reference the CGS documentation checklist for lower limb prostheses, available here:

The AOPA has encouraged members to work with their physician partners to ensure documentation regarding the need for a microprocessor-controlled prosthetic knee is present in patients’ medical records.

“While the CGS documentation checklist is a useful tool, it does not contain any specific information regarding coverage requirements for microprocessor controlled prostheses,” according to the AOPA press release. “[The] documentation must address the need for a microprocessor knee over a conventional prosthetic knee, as well as support the need for K3 or higher functional level components.”

According to the association, it remains unclear how many claims will be affected by the review, but CGS did indicate the prepayment review will occur across all provider groups that submit claims including L5856.


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