May 26, 2022
Policy Article Revisions Summary for May 26, 2022
Outlined below are the principal changes to the DME MAC Policy Articles (PAs) that have been revised and posted. The policies included are Ankle-Foot/Knee-Ankle-Foot Orthoses, Lower Limb Prostheses, Manual Wheelchair Bases, Orthopedic Footwear, Refractive Lenses, and Transcutaneous Electrical Nerve Stimulators (TENS). Please review the entire Local Coverage Determinations (LCDs) and related PAs for complete information.
Ankle-Foot/Knee-Ankle-Foot Orthoses
PA
Ankle-Foot/Knee-Ankle-Foot Orthoses PA
Revision Effective Date: 02/01/2021
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
- Revised: “Braces Benefit” to “braces benefit”
- Revised: “Coding Guidelines” to “CODING GUIDELINES”
- Revised: “Ankle-Foot Orthosis” to “ankle-foot orthosis”
- Revised: “CAD-CAM” to “computer-aided design/computer-aided manufacturing (CAD/CAM)”
GENERAL REQUIREMENTS:
- Revised: “Coding Guidelines” to “CODING GUIDELINES”
- Revised: “off-the-self” to “OTS”
MODIFIERS:
- Revised: “KX, GA, and GZ MODIFIERS:” to “GA, GZ, KX, LT and RT MODIFIERS:”
- Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
- Revised: Language describing parallel code set availability for identical types of products
- Revised: Coding guideline language for HCPCS codes L1900, L1902, L1904, L1906, L1907, L1910, L1920, L1930, L1932, L1940, L1945, L1950, L1951, L1960, L1970, L1971, L1980, L1990, and L2006
- Revised: Coding guideline information for HCPCS codes L1910, L1932, and L1951, to include that there are no additional HCPCS codes for these types of orthoses
- Added: Long HCPCS descriptions to coding guidelines for HCPCS codes L2006, L2340, and L2755
- Revised: Language describing the coding of foot orthotics as L-codes or A-codes
- Revised: “Durable Medical Equipment” to “durable medical equipment”
- Revised: “Braces” to “braces”
- Revised: Format of long HCPCS descriptions for HCPCS codes A9270 and L4205
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.
Lower Limb Prostheses
PA
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.
Manual Wheelchair Bases
PA
Revision Effective Date: 01/01/2020
POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:
- Removed: Reference to ADMC program-specific information
05/26/2022: At this time the 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.
Orthopedic Footwear
PA
Revision Effective Date: 01/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
- Added: L5220 to the list of partial foot or lower extremity prosthesis HCPCS codes that will result in orthopedic shoes denial when the shoes are put on over the prosthesis
MODIFIERS:
- Added: LT and RT modifiers
- Removed: “code (specific to the 5th digit)”
- Added: “code(s) to the highest level of specificity”
- Added: Statement regarding use of RT and LT, with reference to CODING GUIDELINES section for additional information
CODING GUIDELINES:
- Added: L5220 to the list of other types of leg prostheses that must not be used with HCPCS code L3250
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.
Refractive Lenses
PA
Revision Effective Date: 10/01/2020
NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:
- Revised: "Prosthetics and Artificial Limbs" to "prosthetic devices"
CONTINUED MEDICAL NEED:
- Added: Section header and continued medical need language
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.
Transcutaneous Electrical Nerve Stimulators (TENS)
PA
Transcutaneous Electrical Nerve Stimulators (TENS) PA
Revision History Effective Date: 11/20/2021
MODIFIERS:
- Removed: Q0 (zero) modifier from sub-header
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.
Note: The information contained in this article is only a summary of revisions to the LCDs and/or PAs. For complete information on any topic, you must review the LCDs and/or PAs.
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