Prostheses Billing Services
Turn complex DMEPOS rules into predictable cash flow. From first-fit lower-limb prostheses to upper-limb myoelectric devices, liners, sockets, and component upgrades—prosthetics billing isn’t “regular” medical billing. It’s a maze of HCPCS L-codes, modifiers, K-level documentation, prior authorizations, proof-of-delivery, and payer-by-payer quirks. Sirius Solutions Global specializes in Prostheses Billing Services that protect revenue while keeping you audit-ready and patient-focused.
Our Prostheses Billing Services (end-to-end DMEPOS RCM)
We build a billing engine around how prosthetists actually work fast, compliant, and thorough.
1) Eligibility & Benefits Verification
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Real-time coverage, deductibles, coinsurance, and prior-auth needs are checked in real-time.
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Frequency and replacement rules surfaced upfront to prevent surprises.
2) Prior Authorization Management
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We assemble the clinical packet: face-to-face notes, prosthetist evaluation, functional assessment (incl. K-level rationale), therapy/gait documentation, photos, component specs, and justifications.
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Submit, track, and escalate until a determination is issued.
3) L-Code Strategy & Charge Capture
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Accurate HCPCS selection for:
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Initial & definitive prostheses (BK/AK, partial foot, upper limb)
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Myoelectric & microprocessor components (knees, ankles, hands)
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Sockets (test, preparatory, definitive) and suspension systems
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Liners, sleeves, sheaths, socks, and other supplies
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Repairs/adjustments and component replacements
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Modifiers applied correctly (e.g., RT/LT, KX, RA for replacement, RB for replacement part, NU new item) with clear medical necessity notes.
4) Clean Claims & Payer-Specific Edits
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Rule engines check: K-level alignment, diagnosis linkages, frequency limits, add-on compatibility, serial/lot requirements, and place-of-service rules—before submission.
5) Denial Management & Appeals
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Root-cause analysis by denial type (medical necessity, POD, modifier, pricing).
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Rapid resubmission with addenda, component specs, or clarified functional evidence; formal appeals for high-value claims.
6) Payment Posting & Underpayment Recovery
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ERA/EOB posting with contract audits to find short-pays.
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Automated underpayment alerts and follow-through until the variance is resolved.
7) Patient Billing That Makes Sense
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Clear statements, payment options, and helpful support reduce confusion and complaints.
8) Reporting & KPIs You’ll Actually Use
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Net collection rate, first-pass acceptance, AR by payer, denial categories, turnaround time by device type, and top L-code revenue.
Typical results our clients see
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Higher first-pass acceptance (cleaner claims, fewer pends)
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Reduced denials & rework for medical necessity and documentation
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Recovered underpayments through systematic contract auditing
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Shorter AR cycles and more predictable cash flow
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Happier clinical teams less paperwork ping-pong
Why prosthetic billing is uniquely hard
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L-codes & add-ons: Each socket, knee, foot, suspension, liner, and accessory has its own L-code; bundles and exclusions are easy to miss.
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K-level documentation: Coverage and component selection often hinge on functional level (K0–K4) and objective testing - if it’s not documented, it’s denied.
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Replacement versus restoration versus upgrade: different standards, corrections, and paperwork; mistakes lead to recoveries.
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By prior authorization and frequency restrictions, demands vary depending on payer and gadget type (e.g., myoelectric hands, microprocessor knees).
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Proof of delivery (POD) and supplier requirements: missing serials or signatures can result in refusals even with evident medical necessity.
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Everyone has its own pricing plan, schedules, and forms: VA, Medicaid, commercial, and workers' comp.
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Audit pressure: High-cost components mean more scrutiny, pre- and post-payment reviews, and documentation requests.
If your team is constantly chasing paperwork, fixing NCCI edit issues, or re-submitting for “insufficient documentation,” you’re leaking revenue.
What we handle every day
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Initial, preparatory, and definitive limbs (BK/AK, hip disarticulation, partial foot, upper limb)
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Microprocessor knees/ankles and myoelectric hands with rich functional justification
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Socket replacements for limb volume/shape change; alternate suspension systems
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Component upgrades (feet, knees, terminal devices) when function demands
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Repairs vs. replacements with correct modifiers and documentation
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Liners, socks, sleeves, sheaths, and supply cadence by payer rule
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Pediatric growth-related replacements and school/therapy documentation
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Workers’ comp, VA, Medicaid, commercial, Medicare each with its own playbook
Documentation that wins approvals
We help teams document what payers actually look for without creating busywork.
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Functional level (K0–K4) with objective tests (e.g., gait speed, AMP-style measures) and real-world activity goals.
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Medical necessity narrative tied to daily activities, terrain, vocational/safety needs, fall risk, and comorbidities.
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Component rationale (e.g., microprocessor knee for variable cadence, stumble recovery, uneven terrain, or energy efficiency).
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Fit and delivery details: serial numbers, sizing, alignment, adjustments, and patient training.
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Replacement triggers: residual limb change, irreparable damage, wear beyond repair, or clinical need for upgraded technology.
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Proof of delivery (POD): compliant forms, signatures, and serials captured and stored.
We provide concise templates and checklists so busy clinicians can document quickly and defensibly.
Technology & AI that quietly prevents revenue loss
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AI claim scrubbing catches missing modifiers, incompatible add-ons, frequency conflicts, and documentation gaps.
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Denial prediction flags risky claims (e.g., microprocessor components without robust K-level evidence) for pre-submission review.
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Smart payment analytics compare remittances to contracted rates; short-pays trigger automatic worklists.
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Integrations of EHR/PM help to reduce manual data input, missed Lcodes, and POD discrepancies.
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Realtime dashboards reveal payer, device, and site bottlenecks as well as opportunities.
Automation is used for the regular inspections; humans are employed for the clinical nuance.
Quick Helpful Answers
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Ready to make prosthetic billing predictable
If denials, short-pays, or endless paperwork are wearing your team down, let’s fix the revenue engine behind your patient care. Request a no-cost prosthetics revenue audit - we’ll pinpoint where claims stall, what documentation to tighten, and the fastest path to cleaner cash flow.