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March 12, 2020

LCD and Policy Article Revisions Summary for March 12, 2020

Outlined below are the principal changes to the DME MAC Local Coverage Determinations (LCDs) and Policy Articles (PAs) that have been revised and posted. The policies included are Lower Limb Prostheses, Power Mobility Devices, and Wheelchair Seating. Please review the entire LCDs and related PAs for complete information.

Lower Limb Prostheses

LCD

Lower Limb Prostheses LCD

Revision Effective Date: 01/01/2020

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS
Revised: "physician" to "practitioner"
Revised: "physician's" to "treating practitioner's"
Revised: Order information as a result of Final Rule 1713

CODING INFORMATION:

Removed: Field titled "Bill Type"
Removed: Field titled "Revenue Codes"
Removed: Field titled "ICD-10 Codes that Support Medical Necessity"
Removed: Field titled "ICD-10 Codes that DO NOT Support Medical Necessity"
Removed: Field titled "Additional ICD-10 Information"

DOCUMENTATION REQUIREMENTS:

Revised: "physician's" to "treating practitioner's"

GENERAL DOCUMENTATION REQUIREMENTS:

Revised: Prescriptions (orders) to SWO

03/12/2020: Pursuant to the 21st Century Cures Act, these revisions do not require notice and comment because they are due to non-discretionary coverage updates reflective of CMS FR-1713, HCPCS code changes, and non-substantive corrections (listing individual HCPCS codes instead of a HCPCS code-span).

PA

Lower Limb Prostheses PA

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.

Power Mobility Devices

LCD

Power Mobility Devices LCD

Revision Effective Date: 01/01/2020

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

Added: Definition of "treating practitioner"
Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS

MISCELLANEOUS:

Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS
Revised: Reference to weight range capacity for heavy duty PWCs and POVs from "400" to "450"

CODING INFORMATION:

Removed: Field titled "Bill Type"
Removed: Field titled "Revenue Codes"
Removed: Field titled "ICD-10 Codes that Support Medical Necessity"
Removed: Field titled "ICD-10 Codes that DO NOT Support Medical Necessity"
Removed: Field titled "Additional ICD-10 Information"

POLICY SPECIFIC DOCUMENTATION REQUIREMENTS:

Revised: Section information to include SWO for options/accessories, WOPD for PMD base item, and face-to-face encounter related information
Added: Statement indicating that if the supplier does not receive SWO (for the PMD base) prior to delivery, the claim will deny as not reasonable and necessary

PA

Power Mobility Devices PA

Revision Effective Date: 01/01/2020

NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES:

Revised: Order and face-to-face encounter denial-related information
Revised: Section information to include that if the treating practitioner does not conduct the face-to-face encounter and write the SWO for the PMD base, the claim will deny as statutorily non-covered

FACE-TO-FACE ENCOUNTER:

Revised: Section information related to face-to-face encounters, LCMP evaluation, and 6-month timeframe
Removed: Custom motorized/power wheelchair base (K0013) information

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

MISCELLANEOUS:

Added: Custom motorized/power wheelchair base (K0013) information, previously located in FACE-TO-FACE ENCOUNTER section

CODE-SPECIFIC REQUIREMENTS:

Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS

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.

Wheelchair Seating

LCD

Wheelchair Seating LCD

Revision Effective Date: 01/01/2020

COVERAGE INDICATIONS, LIMITATIONS, AND/OR MEDICAL NECESSITY:

Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS
Removed: Statement to refer to ICD-10 Codes that are Covered section in the LCD-related PA
Added: Statement to refer to the ICD-10 code list in the LCD-related Policy Article
Revised: Order information as a result of Final Rule 1713

CODING INFORMATION:

Removed: Field titled "Bill Type"
Removed: Field titled "Revenue Codes"
Removed: Field titled "ICD-10 Codes that Support Medical Necessity"
Removed: Field titled "ICD-10 Codes that DO NOT Support Medical Necessity"
Removed: Field titled "Additional ICD-10 Information"

DOCUMENTATION REQUIREMENTS:

Revised: "physician's" to "treating practitioner's"

GENERAL DOCUMENTATION REQUIREMENTS:

Revised: Prescriptions (orders) to SWO

PA

Wheelchair Seating PA

Revision Effective Date: 01/01/2020

REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO 42 CFR 410.38(g):

Removed: Section due to Final Rule 1713

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 REQUIREMENTS:

Revised: "ICD-10 Codes that are Covered" to "ICD-10 code list"
Revised: Information related to GY modifier use, as a result of Final Rule 1713

CODING GUIDELINES:

Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS

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"
Revised: Format of HCPCS code references, from code 'spans' to individually-listed HCPCS, in Groups 2 and 3 Paragraphs

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.

Note: The information contained in this article is only a summary of revisions to the LCDs and PAs. For complete information on any topic, you must review the LCDs and/or PAs.

License for Use of "Physicians' Current Procedural Terminology", (CPT) Fourth Edition

AMA Disclaimer of Warranties and Liabilities.

CMS Disclaimer

POINT AND CLICK LICENSE FOR USE OF "CURRENT DENTAL TERMINOLOGY", ("CDT")

LCD and Policy Article Revisions Summary for March 12, 2020

Lower Limb Prostheses

LCD

PA

Power Mobility Devices

LCD

PA

Wheelchair Seating

LCD

PA

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