Slide 1

Documentation & Requirements

Slide 2

Coverage Criteria & K Levels

Replacement Criteria

Repairs & Adjustments

Orthotic & Prosthetic Documentation

Requirements

Billing

Slide 3

Coverage Criteria &K Levels

Slide 4

A lower limb prosthesis is covered when the patient:

o Will reach or maintain a defined functional level ( K

level ) within a reasonable period of time

o Is motivated to ambulate and use the device including

motivated to put in the work to learn to use it properly.

o Their goal can range from Running, walking, walking

with assistance, standing with minimal walking, and

even transferring

Slide 5

• A determination of the medical necessity for certain components /

additions to the Px is based on the patient’s potential functional abilities.

• Potential functional ability is based on the reasonable expectations of the

prosthetist, and treating physician, considering factors including, but not

limited to:

o The beneficiary’s past history (including prior prosthetic use if

applicable)

o The beneficiary’s current condition including the status of the

residual limb and the nature of other medical problems

o The beneficiary’s desire to ambulate.

Slide 6

- The K-Level system was devised by Medicare as an attempt to classify prosthetic

components according to the patient population.

- Patients are assigned a K-Level, typically by their Prosthetist, which is used as a

guideline when choosing prosthetic components (i.e. feet or knees).

- An amputee's K-Level is designed to be fluid, meaning that an individual may

move through a variety of K-Levels throughout his/her life.

- The K Levels when classified at Evaluation are many times seen as a K Level

potential. This means the patient may have the POTENTIAL to reach the said

K Level in the next 2 – 6 months.

Slide 7

A few of the criteria that are taken into consideration are:

o Patient’s activity Level before amputation

• Very active, Active, Moderate, Low , Non-existent

• How long it has been since they walked and when they did what is any

assistive devices were used

o Any medical conditions that may limit their function

• Heart condition, Stroke, Limited lung function

o Manual Muscle Test & Range of Motion

• Limited range or contractures can effect the Level Potential. Also the patients

and their manual dexterity , and strength in both limbs ; especially the contra

lateral non amputated side, can all effect the decision.

Slide 8

Does not have the ability or potential to ambulate or transfer safely

with or without assistance and a prosthesis does not enhance their

quality of life or mobility.

- May have severe contractures caused by sitting for long periods of

time or other medical conditions that limit function

- MMT level of Grade 2+ or lower

Slide 9

• Has the ability or potential to use a prosthesis for transfers or

ambulation on level surfaces at fixed cadence.

• Typical of the limited and unlimited household ambulator

• MMT level of Grade 3 to 3+ Potential

Slide 10

• Has the ability or potential for

ambulation with the ability to

traverse low level

environmental barriers such

as curbs, stairs or uneven

surfaces.

• Typical of the limited

community ambulator.

• MMT Grade 3+ to 4 Potential

Slide 11

• These individuals can accommodate for "low level" environmental

obstacles including curbs, bumps and sidewalk cracks. They can

walk for limited periods of time but cannot typically vary their

walking speed.

Slide 12

• If amputees have the ability to vary their

speed and can traverse through a variety of

environmental obstacles, they are

considered to be a K-3. These individuals

can walk through a variety of

environments (grass, rocks, hills, sand

etc.) without difficulty. The prosthetic is

used for recreational and moderate

exercise activities

Slide 13

• Has the ability or potential for ambulation with

variable cadence.

• Typical of the community ambulator who has

the ability to traverse most environmental

barriers and

• May have vocational, therapeutic, or exercise

activity that demands prosthetic utilization

beyond simple locomotion.

• MMT Grade 4 to 5 Potential

Slide 14

Slide 15

• Has the ability or potential for

prosthetic ambulation that exceeds

basic ambulation skills

• Exhibiting high impact, stress, or

energy levels. Typical of the prosthetic

demands of the child, active adult, or

athlete.

Slide 16

Slide 17

• Use modifiers to indicate functional level

K0 , K1, K2, K3, K4

• The records must document the beneficiary’s current

functional capabilities and his/her expected functional

potential, including an explanation for the difference, if that is

the case.

• It is recognized within the functional classification hierarchy

that bilateral amputees often cannot be strictly bound by

functional level classifications.

Slide 18

The following items are included in the reimbursement for a prosthesis and, therefore,

are not separately billable to Medicare under the prosthetic benefit:

• Evaluation of the residual limb and gait.

• Fitting of the prosthesis.

• Cost of base component parts and labor contained in HCPCS

• base codes.

• Repairs due to normal wear or tear within 90 days of delivery

• Adjustments of the prosthesis or the prosthetic component made when

fitting the prosthesis or component and for 90 days from the date of

delivery when the adjustments are not necessitated by changes in the

residual limb or the patient's functional abilities.

Slide 19

Replacement Criteria

Slide 20

• Replacement of prosthesis or major

components must be supported by a new

Physicians order.

• Replacement of a prosthesis or prosthetic

component is covered if:

o Change in physiological condition of the

patient

o Irreparable wear of the device or part

o Repairs that will exceed 60% if the cost for

a new device

Slide 21

The time frame for a replacement socket according to Medicare guidelines is:

Socket Replacement :

6-12 months which is dependent on volumetric and anatomical

change

All New Prosthesis:

2 years unless there has been a functional level change or the

equipment was provided by another company and does not meet

the patients needs. i.e.: wrong level of equipment for patients

current or anticipated K Level.

Slide 22

Repairs & Adjustments

Slide 23

• A repair is a restoration of the prosthesis to correct problems due to

wear or damage.

• An adjustment is any modification to the prosthesis due to a change

in the patient's condition or to improve the function of the prosthesis.

• Maintenance which may be necessitated by the manufacturer’s

recommendations or construction and must be performed by the

prosthetist to be covered.

Slide 24

Prosthetic Documentation Requirements

Slide 25

• Suppliers must have an order from the

treating physician before dispensing a

prosthesis to a beneficiary.

• If the item(s) is delivered prior to obtaining

a detailed written order, the supplier must

obtain a dispensing order prior to delivery.

• The dispensing order may be written, faxed

or verbal.

Slide 26

• The dispensing order must include:

o A description of the item

o The beneficiary’s name

o The physicians signature ( if written ) or the supplier’s signature (

Verbal )

o The name of the physician

o The date of the order

The Supplier must maintain written documentation of the

dispensing order and this documentation must be available upon

request.

Slide 27

• In order for a Practitioner

to talk to and evaluate a

patient for a prosthesis

there must be a signed

order to do so.

Slide 28

• The dispensing written order must include:

o The beneficiary’s name

o A detailed description of each separately billed component

o The ordering physician’s signature

o The date the ordering physician signed the order and

o The start date of the order * If different from the signature

date

Slide 29

AFO & KAFO

L1906, L1932, L1960, L1932, L1960, L1990

As well as custom KAFO codes from L2126-L2136

AFO’s and KAFO’s that are custom fabricated are covered for ambulatory beneficiaries when the basic coverage criteria listed above and one of the following criteria are met:

1.The beneficiary could not be fit with a prefabricated AFO; or,

2.The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,

3. There is a need to control the knee, ankle or foot on more than one plane; or,

4. The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,

5. The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.

Slide 30

Knee orthoses L1832, L1843 and L1845 are

also covered for a beneficiary who is

ambulatory and has knee instability due to

a condition specified in any diagnosis

listed below

Slide 31 Diagnosis ICD-9

Rheumatoid arthritis 714.0 – 714.4

Osteoarthritis 715.16, 715.26, 715.36, 715.96

Meniscal cartilage derangement 717.0 – 717.5

Chondromalacia of patella 717.7

Knee ligamentous disruption 717.81 – 717.9

Rupture of tendon, non-traumatic - quadriceps tendon 727.65

Rupture of tendon, non-traumatic, site-patellar tendon 727.66

Pathologic fracture of femur 733.15

Pathologic fracture of tibia or fibula 733.16

Aseptic necrosis of tibia or fibula 733.49

Malunion of fracture – nonunion of fracture 733.81-733.82

Stress fracture of tibia or fibula 733.93

Congenital deformity of knee 755.64

Fracture of femur - lower end 821.20 – 821.39

Fracture of patella 822.0, 822.1

Fracture of tibia and/or fibula - upper end 823.00 – 823.42

Dislocation of knee 836.0 – 836.69

Sprains and strains of knee 844.0 – 844.2, 844.8

Late effect of fracture of lower extremities 905.4

Failed total knee arthroplasty 996.40 – 996.49, 996.66, 996.77, V43.65

Slide 32

or one of the following diagnoses

Slide 33

Diagnosis ICD-9

Multiple sclerosis 340

Hemiplegia, unspecified; dominant side; non-dominant side 342.90, 342.91, 342.92

Infantile cerebral palsy, unspecified 343.9

Paraplegia of both lower limbs 344.1

Mononeuritis of lower limb, unspecified 355.0, 355.2

Slide 34

Billing

Slide 35

• Payment for a prosthesis described by codes L5000-L5020 and L5400-L5460 is included in the payment when delivered to a Hospital if:

1. The prosthesis is provided to a beneficiary during Medicare Part A stay 2 days prior to the day of discharge;

2. The beneficiary uses the prosthesis for medically necessary inpatient treatment or rehabilitation and intends to take the prosthesis home.

Slide 36

• Claims for lower limb prosthesis provided to beneficiaries under Medicare Part B coverage in a SNF are submitted directly to the DME MAC.

• In addition, any claims for lower limb prosthesis provided in a SNF when the stay is under Medicare Part A, are also submitted directly to the DME MAC.

Slide 37

• For orthotics, Medicare will not pay for a

device if the patient is staying at a facility

(hospital or SNF) under Part A. If a device is

needed, the facility will be responsible for

payment.

• When the patient goes under Medicare Part B

(long term stay), then the device will be paid

for. Maximum allowable time for Medicare

Part A coverage is 100 consecutive days.

Slide 38

• Activities of Daily Living

• Prosthetic Usage Skills

• Education of Patient and

of Family members

Slide 39

• Pre and Post Prosthetic management

programs for various level amputees

• Shaping and care of the residual limb

• Exercise and functional training based

on patient’s age and medical

condition

• Safety issues with ADL

Slide 40

Thank You!ANY QUESTIONS?