Healthcare Fraud Shield Latest Article: Let’s Take a Look at Custom Prosthestics

30 May
What is a prosthetic?
A prosthetic is an artificial replacement for a body part; such as a leg or an arm. The prosthetic may be cosmetic only or it may provide functional use for the individual.   A custom prosthetic is fitted to each patient to match that person’s needs.

What is a custom breast prosthesis?
A custom breast prosthesis is made from a mold of the patient’s breast. Subsequently, a custom prosthesis is designed and built to mirror the size and shape of the original breast.  

Is this covered?
Remember to check your respective plan policies as some plans may not cover this item, however, a custom breast prosthesis is usually covered for a patient who has had a mastectomy. The custom prosthesis is billed using HCPCS (Healthcare Common Procedure Coding System) code L8035. Most plans do not cover more than one custom prosthetic per breast. Some plans do not consider a custom prosthetic medically necessary and instead cover a prefabricated prosthetic typically billed under L8030.

What to look for?
When analyzing claims data there are several areas for review:
  • Look for providers billing excessive units of a custom prosthetic compared to their peers. Code(s) to review include, but are not limited to L8035.
  • Look for providers billing excessive units of prefabricated prosthetics compared to their peers. Code(s) to review include, but are not limited to L8030, L8031, L8032, L8039.
  • Look for providers billing excessive units of mastectomy bras and supplies compared to their peers.   Code(s) to review include, but are not limited to A4280, L8000, L8001, L8002, L8015.
  • Look for providers upcoding mastectomy bras. There are several HCPCS codes related to breast prosthetics and mastectomy bras.  For example, L8300 (Breast prosthesis, mastectomy bra, without integrated breast prosthesis form, any size, any type) has a ceiling of $111.25 under the DMEPOS fee schedule1, whereas L8035 (custom breast prosthetic) has a ceiling of $4,341.16.
If you have any questions or comments, please contact SIU@hcfraudshield.com.

 

REFERENCES


1. These rates are according to the April 2019 DMEPOS Fee Schedule. Ceiling represents 120% of the average of the regional statewide fees 

 

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