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Commonly Seen Incorrect Reasons for Appeal
Incorrect Reasons for Appeals for L5940 & L5950
One of the most common appeals we receive is for the L5940 or L5950. Usually the denial is due to the claim being split and separating the L5940 or L5950 from the Medicare approved endoskeletal system or socket. However, there are situations when the claim cannot be appealed. Prior to appealing the claim, the following two factors need to be reviewed:
Is the claim billed with a Medicare approved endoskeletal system or socket HCPCS code?
CMS published Transmittal 1630 on November 7, 2008 that reads “Contractors shall allow payment for HCPCS code L5940 only when the claim is billed with one of the following endoskeletal system or socket HCPCS codes: L5301, L5311, L5321, L5531, L5341, L5700, L5701, L5702 or L5703.” If none of the approved HCPCS codes appear on the claim, then your claim has denied correctly and cannot be appealed.
Is the claim being billed with knee/shin system, pylon, ankle, foot, etc.?
The Local Coverage Determination states “Codes L5940-L5960 for ultra-light materials may only be used when materials such as carbon fiber, fiberglass, Kevlar®, or other advanced composite lamination materials are used in the fabrication of a socket for an endoskeletal prosthesis. They are not used for ultralight materials used in other components of a prosthesis – e.g., knee/shin system, pylon, ankle, foot, etc. For codes L5940-L5960, the unit of service is per limb.”
There are cases you can bill a claim that will have both a knee/shin system, pylon, ankle, or foot and an endoskeletal system. When this occurs, you want to make sure the prosthetist’s notes indicate what the L5940 or L5950 was used in conjunction with, either the endoskeleton system or socket.
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