C-Leg Microprocessor Knee

C-Leg Microprocessor Knee
Billing Tips for the Miscellaneous Codes
Effective: April 27, 2015
SUGGESTED CODING 1
Ottobock intends to apply for a new Healthcare Common Procedure Coding System (HCPCS) code to
describe the additional features on the C-Leg microprocessor knee. In the meantime, we recommend
using one miscellaneous code in addition to the existing codes listed below.
The following codes are PDAC approved for C-Leg
L5828
SINGLE AXIS, FLUID (HYDRAULIC), SWING AND STANCE PHASE KNEE.
L5845
STANCE FLEXION FEATURE, ADJUSTABLE
L5848
FLUID STANCE EXTENSION DAMPING FEATURE
L5856
MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE,
INCLUDES SENSORS (K3 or above for Medicare)
L5920
ALIGNABLE SYSTEM
L5930
HIGH ACTIVITY KNEE CONTROL FRAME (sometimes restricted to K4)
L5950/L5960 ULTRALIGHT MATERIAL (TITANIUM, CARBON FIBER, OR EQUAL)
(Medicare only allows K5950 and L5960 when added to a socket)
Additional codes for the new functionality of C-Leg
L5850
KNEE EXTENSION ASSIST
L5925
MANUAL LOCK
L5999*
ADDITION TO ENDOSKELETAL SYSTEM (OTTOBOCK 3C98 / 3C88 CLEG), INERTIAL MOTION UNIT CONTROL FEATURE FOR INTUITIVE
STANDING AND WALKING BACKWARDS.
C-Leg Protective Cover with Shield Insert
L5999
ADDITION TO LOWER LIMB PROSTHESIS, OTTOBOCK 4X860 C-LEG
PROTECTIVE COVER AND 4P863 SHIELD INSERT
C-Leg Battery and Charger
L7367
LITHIUM ION BATTERY, REPLACEMENT
L7368
LITHIUM ION BATTERY CHARGER, REPLACEMENT
* It is not recommended to bill Medicare miscellaneous codes (e.g. L5999) for microprocessor knees.
Ottobock
800.328.4058
http://professionals.ottobockus.com
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C-Leg Microprocessor Knee
Billing Tips for the Miscellaneous Codes
Effective: April 27, 2015
BILLING TIPS FOR THE C-LEG MISCELLANEOUS CODE - L5999
Because L5999* is an unlisted (NOC) code, the claim must have additional information to describe
the item, so that the payer can tell what you are billing them for. Most payers require a narrative be
added to the claim (e.g. device name, manufacturer, model/serial number, and MSRP). Please
check with your software vendor and payer for where to add the narrative.
WHERE TO PUT THE NARRATIVE
Electronic2
Claim
Notes can be added in 3 places in ANSI format electronic claims. The 2300 NTE
Segment, the SV101-7 and the 2400 NTE Segment. The 2300 NTE segment
pertains to the entire claim. The SV101-7 and 2400 NTE segments pertain to each
line item.
2300 NTE Segment: Put information here about the overall device you are billing
for (socket, knee, ankle, foot, etc.)
SV101-7 and 2400 NTE Segments:* Put information here about L5999
Examples:
ADDITION, INERTIAL MOTION CONTROL FEATURE ON OTTOBOCK
3C98 C-LEG MSRP $ ______
ADDITION, OTTOBOCK 4X860 C-LEG PROTECTIVE COVER W/ 4P863
SHIELD INSERT MSRP $_____
* SV101-7 and NTE 2400 segments are limited to 80 characters (including spaces)
Paper Claim3
Enter entire narrative on Line 19 when submitting a hand-written paper claim
(CMS-1500). Include the HCFA 1500 line number that the NOC code is located
on.
Examples:
Line____: L5999 ADDITION, INERTIAL MOTION CONTROL FEATURE ON
OTTOBOCK 3C98 C-LEG MSRP $ ______
Line____: L5999 OTTOBOCK 4X860 C-LEG PROTECTIVE COVER W/
4P863 SHIELD INSERT MSRP $ ______
2015 MANUFACTURER SUGGESTED RETAIL PRICE (MSRP)4
MSRP for the Inertial Motion Control Unit miscellaneous (NOC) code is $5,000
MSRP for the 4X800 Protective Cover miscellaneous (NOC) code is $2100
MSRP for the 4P863 Shield Insert miscellaneous (NOC) code is $300
Ottobock
800.328.4058
http://professionals.ottobockus.com
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C-Leg Microprocessor Knee
Billing Tips for the Miscellaneous Codes
Effective: April 27, 2015
MEDICAL REVIEW
Sometimes codes requiring narratives are sent to Medical Review regardless of proper claim
submission. If this happens, you will need to submit all documentation (including proof of medical
necessity and reason for replacement) as the claim will likely undergo medical necessity review.
CONCLUSION
Following these instructions will help you have a more successful outcome. For additional
reimbursement information, or if you have questions about this material, please contact Otto Bock
Reimbursement at 800.377.0338.
© 2015 Otto Bock HealthCare LP ● 11Cleg.04262015
References
1
The product/device “Supplier” (defined as an O&P practitioner, O&P patient care facility, or DME
supplier) assumes full responsibility for accurate billing of Ottobock products. It is the Supplier’s
responsibility to determine medical necessity; ensure coverage criteria is met; and submit
appropriate HCPCS codes, modifiers, and charges for services/products delivered. It is also
recommended that Supplier’s contact insurance payer(s) for coding and coverage guidance prior to
submitting claims. Ottobock Coding Suggestions and Reimbursement Guides are based on
reasonable judgment and are not recommended to replace the Supplier’s judgment. These
recommendations may be subject to revision based on additional information or alpha-numeric
system changes.
2
Billing Instructions for Durable Medical Equipment, Prosthetics, Orthotics and Supplies
(DMEPOS) Submitted with a Not Otherwise Classified (NOC) HCPCS. NHIC Corp., DME MAC
Jurisdiction A Resource. June 2013;28:87-88; Revised: Billing a Not Otherwise Classified Health
Care Common Procedure Coding System Code. National Government Services, DME MAC
Jurisdiction B. January 2014; Noridian Healthcare Solutions, LLC, DME MAC Jurisdiction D.
Electronic Claim Narratives.
3
NHIC Corp. DME MAC Jurisdiction A Supplier Manual, Chapter 3, Health Insurance Claim Form,
Instructions for line 24D; National Government Services, DME MAC Jurisdiction B Supplier Manual
Chapter 12, Claim Submission. Instructions for line 24D; CGS Administrators, LLC. DME MAC
Jurisdiction C Supplier Manual, Chapter 6, Claim Submission. Item 24D; Noridian Healthcare
Solutions, LLC, DME MAC Jurisdiction D. Keys to Successful Claims Filing.
4
The manufacturer’s suggested retail pricing (MSRP) is a suggested retail price only. Ottobock has
provided the suggested MSRP in the event that third-party and/or federal healthcare payer’s request
it for reimbursement purposes. The practitioner and/or patient care facility is neither obligated nor
required to charge the MSRP when submitting billing claims for third-party reimbursement for the
product (s).
Ottobock
800.328.4058
http://professionals.ottobockus.com
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