Upper Limb Prosthetics

Billing Basics

Except for repairs to existing devices, prosthetists cannot bill for their time.  The only thing they can bill for is the device that they deliver.   There are positives and negatives to this.  The negative is that all the costs of the business:  the time of the practitioner, the technician, the receptionist, the rent for the building, the toner for the Xerox machine, all of it—must be accounted for in the cost of the prosthesis.  That is why they are so expensive.  On the plus side, you are not charged per visit to the office or for how long you spend there.  While you may not want to spend the time, there is no financial reason not to go in for an adjustment, to get something checked, or to ask for help.

Prostheses are billed through “L Codes”.  Each L Code represents a feature or component of the prosthesis, and a final bill will be a list of many.

For example:  
  • L6110 – Below Elbow, molded socket
  • L6686 – Upper extremity addition, suction socket
  • L6615 – Upper Extremity Addition, disconnect locking wrist unit
  • L6660 – upper extremity addition, heavy duty control cable
  • L6722 – Terminal device, hook or hand, heavy duty, mechanical, voluntary closing, any material, any size, lined or unlined.

These are just a few.  There are dozens of choices.

Each L code has a price associated with it that varies slightly depending on the area of the country you live in.  That price represents the amount that Medicare will reimburse the prosthetist for that feature or component.  Almost all other insurance companies also go by the guidelines and prices outlined by Medicare.

In this way, the practitioner cannot set the price of the prosthesis, and the same device/set of codes will cost the same no matter what practitioner you go to.  Where a price differential WILL come into play is when different practitioners would make you different devices.  One may want to make a myo prosthesis with lots of features or components that will cost more, whereas another practitioner may want to make a body powered prosthesis that will cost less.

Some prosthetists may require prior authorization or ask you to sign a guarantee of financial responsibility before they will begin the fitting process.  Try not to judge them too harshly for that.  The insurance company may deny part or all of the claim, and few people have the financial resources to pay for a prosthesis out of pocket.  Your prosthetist won't want to abandon you or take the device away from you, but they can't work for free.  They have to stay in business in order to help people.  Even if the insurance does agree to cover the prosthesis, if you drop out of the process at any point or get to the end and decide you don’t want it, your prosthetist probably can’t bill Medicare or insurance for anything they have done.  That is a lot of money for them to absorb—especially in the case of myo electric stuff (those components are expensive and they might not be able to return them).  And many patients do lose enthusiasm or change their mind along the way. 

Another factor is that creating new L Codes for new technologies is a very slow and very political/legislative process.  Because of the small number of patients and the even tinier number of practitioners dealing with these things on a regular basis, L Codes cannot keep pace with the rapidly evolving technology.  Many practitioners leading the way in upper limb prosthetic design have to bill for certain things using the ‘miscellaneous’ L Code, which Medicare and Insurance don’t like to cover.  How the prosthetist deals with these uncovered charges will vary.

Definitely have a detailed discussion with your prosthetist about the finances involved. 

How much the device is expected to cost?

How much would you would likely be responsible for? Best case scenario?  Worst case scenario?

How long are the components expected to last? How much will it cost to maintain and replace them? 

What happens if the insurance denies some or all of the claim? 

What procedures do they have for appealing or re-submitting?

Insurance Authorization

Motion Control has some pointers and suggestions about insurance reimbursement of myo electric devices in general  
http://www.utaharm.com/files/  On their site, go to the Folder menu on the left, click on Resources folder, then Funding Info.

Don’t be afraid to tell your prosthetist about it or print it out and give it to them.

Each L Code generally has to be accompanied by a ‘justification’ explaining why you need it for the 3rd party payer to consider covering it.

For example, you may need:

  • a silicone liner because any other suspension system would cause skin problems due to your extensive scarring.
  • a special socket design because of other injuries to your residual limb.
  • a heavy duty cable and TD because you work daily on a farm
  • 2 different TD’s and a wrist that allows you to change them because you have several different specific activities that require different features.

The ability to get a device and its components covered depends partly on the insurance company (both on their policies and on the person that happens to process it) and partly on the practitioner’s ability to justify it.  People vary in their skill at doing this.  I am NOT saying that if you get denied it’s because your prosthetist didn’t do it right.  Not at all.  Getting coverage for an upper limb prosthesis is difficult for everyone.  What I am saying is that a denial is not necessarily the final word.  Appeal.  Resubmit.   Add more information.  Try again.

Provide your prosthetist with as much information about your needs and difficulties as you can.

What do you need your prosthesis for the most?

What do you have the most difficulty with?

What basic things can’t you do?

What problems do you encounter?

What makes returning to work the most difficult?  What would make it easier?

How would the prosthesis give you your life back?

You are trying to paint a picture for someone who will never meet you… Who you are, the goals you have, the difficulties you encounter every day, the things that make it difficult to return to work, anything you can think of.

It is your prosthetist’s job to take that information and use it to justify each feature of the prosthesis.

No one likes documenting their problems and challenges for strangers.  But if you give the impression that you are fine and will be successful no matter what—the insurance company might well say, “congrats, now why should we pay for this?”

In addition, this information is of great benefit for you to have for your own sake.  Do you understand what prosthetic choices are most conducive to your goals?  While you may get annoyed at a prosthetist discouraging you from what you want, you may also quickly lose patience with a prosthesis that was the coolest, most advanced one available but doesn’t serve your needs.  If you love fishing, but you can’t fish with it because you can’t get it wet, is it really that great?  If you can’t use it at work because it is too fragile and will break… you get the idea.