Reimbursement & PDAC Approved Products

L5856: Addition to lower extremity prosthesis, endo knee-shin system, microprocessor control feature, swing and stance phase, includes electronic sensor(s), any type.
L5857: Addition to lower extremity prosthesis, endo knee-shin system, microprocessor control feature, swing phase only, includes electronic sensor(s), any type.
L5858: Addition to lower extremity prosthesis, endo knee-shin system, microprocessor control feature, stance phase only, includes electronic sensor(s), any type.
L5973: Endo ankle foot system, microprocessor-controlled feature, dorsiflexion and/or plantar flexion control, includes power source.
L5980: All lower extremity prostheses, flex foot system
L5987: All lower extremity prosthesis, shank foot system with vertical loading pylon

The Prior Authorization Request (PAR) Content

DME MAC coversheet, captures all required content.

• Beneficiary Information
• Supplier information
• HCPCS codes under review
• Type of submission
  • Initial or re-submission
• Expediate review
• Standard Written Order
• Medical Necessity – information which contains Physician notes, Prosthetist notes (that corroborates and provides details consistent with physician records), PT notes along with functional level assessments and patient stated desire to ambulate.

Prior Authorization Submission

You can submit the PAR by mail, fax, electronic submission of Medical Documentation (esMD), or dedicated DME MAC provider portals. You can register with DME MAC to utilize the online portals:

Region B, Region C: www.cgsmedicare.com 
Region A, Region D: www.noridianmedicare.com

PAR Review and Decision

DME MAC will review the PAR and respond within 10 business days. The response will include a detailed decision letter and unique tracking number (UTN), which will be needed for payment. The decision letters will be sent to the address on file with National Supplier Clearinghouse (NSC).

If your practice receives an Affirmative PAR Decision – Valid for 120 calendar days and all approved items must be delivered within those 120 days. Any delays require a new PAR.

• Submit your claim as normal. If you utilize the 1500 Claim Form, the UTN is submitted in the first 14 positions in item 23. All other data submitted in item 23 must begin in position 15.
• Electronic claims- the UTN is submitted in either the 2300 – Claim Information loop or 2400 – Service Line loop in the Prior Authorization reference (REF) segment where REF01 = “G1” qualifier and REF02 = UTN.
• Electronic Submission of Medical Documentation System (esMD) – Use the document/content type “8.4”.

If your practice receives a Non-Affirmative Decision-Two options

• Resubmit the PAR after reviewing the decision and correcting errors. DME MAC will review the new PAR and respond within 10 business days. There is no limit on the number of resubmissions.
• Submit the claim as normal including the UTN, the code(s) will be denied, and you may appeal or consider using an Advance Beneficiary Notice (ABN) with the correct utilization. *See rules for ABN usage.

All claims for items billed to Medicare require a written order/prescription from the treating practitioner as a condition for payment. This written order/prescription is referred to as the Standard Written Order (SWO).

• Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
• Order date
• General description of the item
  • The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number For equipment – in addition to the description of the base item, the SWO may include all concurrently ordered
    options, accessories or additional features that are separately billed or require an upgraded code (list each separately)
  • For supplies – in addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (list each separately)
• Quantity to be dispensed, if applicable
• Treating Practitioner Name or NPI
• Treating practitioner’s signature*

*Signatures must comply with the CMS signature requirements outlined in CMS Internet-Only Manuals 100-08, Program Integrity Manual (PIM), Chapter 3, Section 3.3.2.4. Signature and date stamps are not allowed. Upon request by a contractor, DMEPOS suppliers must provide documentation of the completed SWO.

A WOPD is a completed SWO that is communicated to the DMEPOS supplier before delivery of the item(s). Pursuant to Final Rule 1713 (84 Fed. Reg Vol 217)