Results of Jurisdiction D Lower Limb Prostheses Prepayment Probe

More results from prepayment reviews of lower limb prostheses in Jurisdiction D DMEMAC Medical Review Department below. Based on the continued high error rate (79%)  on claims asociated with L5987, Noridian will close this prepayment probe and open a wide spread targeted review of L5987.

Results of Widespread Prepayment Probe Review of Lower Limb Prostheses (HCPCS L5987) 

Jurisdiction D DME MAC Medical Review Department completed a widespread prepayment probe review of HCPCS codes L5987. This review was initiated based on results of Comprehensive Error Rate Testing (CERT) analysis and previous review results.

The L5987 review involved 99 claims, of which 81 were denied. Based on dollars, this resulted in an overall claim potential improper payment rate of 79%.

Primary Documentation Errors that Resulted in Denial of Claims

Documentation does not support the functional level billed on the claim.
A determination of the medical necessity for certain components/additions to the prosthesis is based on the beneficiary’s potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to: 1. The beneficiary’s past history (including prior prosthetic use if applicable); and 2. The beneficiary’s current condition including the status of the residual limb and the nature of other medical problems; and 3. The beneficiary’s desire to ambulate.

The records must document the beneficiary’s current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.

Documentation does not support medical need for replacement.
Replacement of a prosthesis or prosthetic component is covered if the treating physician orders a replacement device or part because of any of the following: 1. A change in the physiological condition of the beneficiary; or 2. Irreparable wear of the device or a part of the device; or 3. The condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60% of the cost of a replacement device, or of the part being replaced.

Documentation did not support the beneficiary will reach or maintain a defined functional state within a reasonable period of time.
A lower limb prosthesis is covered when the beneficiary:

1.     Will reach or maintain a defined functional state within a reasonable period of time; and

2.     Is motivated to ambulate.

Requested documentation was not received by the contractor within the allotted timeframe.
Suppliers have 45 days from the date of the Additional Documentation Request (ADR) letter to respond. Failure to respond within 45 days may result in partial or complete denial of the claim.

Suppliers are in violation of Supplier Standard #28 when, upon request, they fail to provide requested documentation to a Medicare contractor. Medicare regulations (42 C.F.R 424.516[f]) stipulate that a supplier is required to maintain documentation for seven years from the date of service and, upon the request of CMS or a Medicare contractor, provide access to that documentation. Therefore, the consequences of failure to provide records may not only be a claim denial but also referral to the NSC. The supplier standards can be found in 424 CFR Section 424.57(c).

Going Forward
Based on high error rate, Noridian will close this probe review and begin a widespread targeted review on HCPCS code L5987.

Education Resources
It is important for suppliers to be familiar with the documentation requirements and utilization parameters as outlined in the Lower Limb Prosthesis Local Coverage Determination (LCD) L11453 and Policy Article A25367.

Noridian provides educational offerings by scheduling supplier workshops, training opportunities, and presentations. Educational training and events are located at

Information about probe/error validation reviews may be found in CMS Publication 100-8, Program Integrity Manual (PIM), Chapter 3 located at

This entry was posted in Orthotics and Prosthetics, Prosthetist, re provider, Regulatory and tagged , , , , , , . Bookmark the permalink.

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