Mobility made possible.
Reimbursement, PDAC Approved Products & L-Codes
Your Blatchford team is on hand to support with your coding and reimbursement questions relating to Blatchford products, particularly in relation to the new requirements of Prior Authorization of Lower Limb Prosthetic products. Please reach out to Customer Service or your Blatchford Territory Manager for more information.
Important Resources for Clinicians
Blatchford PDAC Verified Products
The PDAC-Approved badge denotes a product that has been approved by the Pricing, Data Analysis and Coding (PDAC) contractor for one or more of the prior authorization codes as specified in the Healthcare Common Procedure Coding System (HCPCS) codes. † This guide is for reference only. The choice of appropriate codes remains the provider’s sole responsibility to verify the accuracy of the HCPCS codes used, determine the applicability to each patient, and fulfill the medical necessity/claims documentation requirements. Blatchford assumes no responsibility or liability for the provider’s actions.
- Microprocessor Feet
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Hydraulic Ankles
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Echelon PDAC Verification Letter
Suggested L-Codes: L5981, L5968
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E-Carbon Feet
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Elite2 PDAC Verification Letter
Suggested L-Codes: L5981 -
EliteVT PDAC Verification Letter
Suggested L-Codes: L5987, L5984 -
Elite Blade PDAC Verification Letter
Suggested L-Codes: L5980 -
Elite BladeVT PDAC Verification Letter
Suggested L-Codes: L5987, L5984 -
Javelin PDAC Verification Letter
Suggested L-Codes: L5980 -
Epirus PDAC Verification Letter
Suggested L-Codes: L5981, L5986
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- Other Feet
- Microprocessor Knees
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Limb Systems
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Linx PDAC Verification Letter
Suggested L-Codes: L5828, L5845, L5848, L5850, L5856, L5925, L5973
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Suggested L Codes
For all Blatchford products, we have created a Suggested L Code sheet that provides our recommended L codes for each of our lower limb prosthetic products.
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Upcoming Changes to Coding & Billing – What this means for you
Condition of Payment Prior Authorization (PA) Program
Prior Authorization for Lower Limb Prosthetic codes will be implemented in two phases. Phase one will begin September 01, 2020 in one state from each Durable Medical Equipment Medicare Administrative Contractor (DME MAC) jurisdiction: California, Michigan, Pennsylvania and Texas – Cigna Government Services (CGS) will begin accepting requests for prior authorization in Michigan and Texas on August 18, 2020. Phase two will begin December 01, 2020 and expands prior authorization to all remaining states and territories.
Effective January 1, 2021 any product billed with the listed L codes must be listed on the PDAC website. The program does NOT create any new documentation requirements; it simply requires the information be submitted earlier in the claims process.
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Affected HCPS Codes
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 Process of Prior Authorization
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.comPAR 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.
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Standard Written Order
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)
- 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
- 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.
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Written Orders Prior to Delivery (WOPD)
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)
Please note: This page is for reference only. The choice of appropriate codes remains the provider’s sole responsibility to verify the accuracy of the HCPCS codes used, determine the applicability to each patient, and fulfil the medical necessity/claims documentation requirements. Blatchford assumes no responsibility or liability for the provider’s actions.
Need Help or Support?
For information and placing orders, contact customer service between the hours of 8:00 am to 6:00 pm EST.
Customer Service: 800.548.3534 (toll free) / 937.291.3636
Fax: 800-929-3636
Customer Service confirms all orders on the day of receipt. All Next Day and Second Day Air shipments are confirmed with UPS tracking information. Our convenient payment options include VISA, Mastercard and Amex.
The Blatchford Community
For over 130 years Blatchford has designed and produced some of the world's most advanced artificial limbs and mobility solutions.
Need help or support?
For information and placing orders, contact customer service between the hours of 8:00 am to 6:00 pm EST.
Customer Service: 800.548.3534 (toll free) / 937.291.3636
Fax: 800-929-3636
Customer Service confirms all orders on the day of receipt. All Next Day and Second Day Air shipments are confirmed with UPS tracking information. Our convenient payment options include VISA, Mastercard and Amex.
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