LCD/NCD Portal

L11556 FACIAL PROSTHESES

 

Region IV

DME

Jurisdiction C

 

08/05/2011

 

• For any item to be covered by Medicare, it must

o Be eligible for a defined Medicare benefit category.

o Be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member.

o Meet all other applicable Medicare statutory and regulatory requirements.

 For the items addressed in this medical policy, the criteria for "reasonable and necessary" are defined by the following indications and limitations of coverage and/or medical necessity.

• For an item to be covered by Medicare, a written signed and dated order must be received by the supplier before a claim is submitted.

o If the supplier bills for an item addressed in this policy without first receiving the completed order, the item will be denied as not medically necessary.

• A facial prosthesis is covered when there is loss or absence of facial tissue due to disease, trauma, surgery, or a congenital defect.

 

 

Bill Type Codes:

• Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service.

• Absence of a Bill Type does not guarantee that the policy does not apply to that Bill Type.

• Complete absence of all Bill Types indicates that coverage is not influenced by Bill Type and the policy should be assumed to apply equally to all claims.

 

Revenue Codes:

• Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service.

• In most instances Revenue Codes are purely advisory; unless specified in the policy services reported under other Revenue Codes are equally subject to this coverage determination.

• Complete absence of all Revenue Codes indicates that coverage is not influenced by Revenue Code and the policy should be assumed to apply equally to all Revenue Codes.

 

 

CPT/HCPCS Codes

 

• The appearance of a code in this section does not necessarily indicate coverage.

 

 

HCPCS MODIFIERS:

 

AV – Item furnished in conjunction with a prosthetic device, prosthetic or orthotic.

 

EY – No physician or other licensed health care provider order for this item or service.

 

KM - Replacement of facial prosthesis including new impression/moulage.

 

KN - Replacement of facial prosthesis using previous master model.

 

LT - Left side

 

RT - Right side

 

HCPCS CODES:

 

A4364 ADHESIVE, LIQUID OR EQUAL, ANY TYPE, PER OZ

A4450 TAPE, NON-WATERPROOF, PER 18 SQUARE INCHES

A4452 TAPE, WATERPROOF, PER 18 SQUARE INCHES

A4455 ADHESIVE REMOVER OR SOLVENT (FOR TAPE, CEMENT OR OTHER ADHESIVE), PER OUNCE

A4456 ADHESIVE REMOVER, WIPES, ANY TYPE, EACH

A5120 SKIN BARRIER, WIPES OR SWABS, EACH

L8040 NASAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8041 MIDFACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8042 ORBITAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8043 UPPER FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8044 HEMI-FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8045 AURICULAR PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8046 PARTIAL FACIAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8047 NASAL SEPTAL PROSTHESIS, PROVIDED BY A NON-PHYSICIAN

L8048 UNSPECIFIED MAXILLOFACIAL PROSTHESIS, BY REPORT, PROVIDED BY A NON-PHYSICIAN

L8049 REPAIR OR MODIFICATION OF MAXILLOFACIAL PROSTHESIS, LABOR COMPONENT, 15 MINUTE INCREMENTS, PROVIDED BY A NON-PHYSICIAN

V2623 PROSTHETIC EYE, PLASTIC, CUSTOM

V2629 PROSTHETIC EYE, OTHER TYPE

 

 

Documentations Requirements

• Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider".

o It is expected that the patient’s medical records will reflect the need for the care provided.

o The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.

o This documentation must be available upon request.

• An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request.

o Items billed before a signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

• A separate physician order is not required for subsequent modifications, repairs, or replacement of a facial prosthesis. A new order is required when different supplies are ordered.

• When either code V2629 or L8048 is billed, the claim must be accompanied by a brief description of the item in the narrative field.

o When L8048 is provided, a drawing/photograph of the item provided must be available upon request.

• Refer to the Supplier Manual for more information on documentation requirements.

 

Sources of Information and Basis for Decision

 

A25513 - Facial Prostheses - Policy Article - Effective January 2010

 

 

Local Coverage Determination (LCD) for Facial Prostheses (L11556)