PRESENTED BY:

Aaron Sorensen, MBA, CPO, LPO

O and P Billing Solutions, Inc.

General Medicare Coverage Guideline

General Lower Extremity Prosthetic Policy

Knee Coverage Indications and Limitations

Recommended Documentation and SOP Practices

The medical record is not limited to physician’s office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc.

Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary

A determination of the medical necessity for certain components/additions to the prosthesis 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: ◦ The patient's past history

(including prior prosthetic use if applicable); and

◦ The patient's current condition including the status of the residual limb and the nature of other medical problems

Knees

Basic lower extremity prostheses include a single axis, constant friction knee. Other prosthetic knees are considered based upon functional classification

Microprocessor Controlled Knees K3 ◦ L5856 microprocessor

controlled swing and stance, includes electronic sensor(s) any type

◦ L5857 microprocessor controlled swing phase only, includes electronic sensor(s) any type

◦ L5858 microprocessor controlled stance phase only, includes electronic sensor(s) any type

L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below: ◦ Has a microprocessor (swing and stance phase type (L5856))

controlled (electronic) knee ◦ K3 functional level only ◦ Weight greater than 110 lbs. and less than 275 lbs. ◦ Has a documented comorbity of the spine and/or sound limb

affecting hip extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone

◦ Is able to make use of a product that requires daily charging ◦ Is able to understand and respond to error alerts and alarms

indicating problems with the function of the unit If these coverage criteria for the knee component are not met,

L5859 will be denied as not reasonable and necessary.

Set up a “test drive” ◦ Arrange with the

manufacturer a trial fit with the knee

◦ Have the patient wear the knee for a few days at a minimum

◦ Have the patient keep a journal

“Test Drive” Continued ◦ Conduct obstacle

course first day of fitting

◦ Conduct the same obstacle course at end of trial period

◦ Conduct the same obstacle course with current mechanical knee or no prosthesis

“Test Drive” Continued ◦ Objective outcomes

needed ◦ Document the outcomes ◦ Send the results to the PT

or MD Summary

◦ Request results be included in patient records

◦ Request PT and MD document as a visit note “patient’s comments” on difference with the MPK

Communication with PT and MD ◦ Letter explaining

recommended components Why these?

Request these to be documented as part of patient visit note

Request the K-Level to be documented in the visit note

Dr XXX:

Mr. XXX was in today for a prosthetic consultation. His prosthesis has been causing him problems recently. The fit of the prosthesis is off as he has shrunk and he is in 20 ply of sock. Adjustments have been attempted at making the prosthesis more comfortable, all of which have proven to be temporary fixes at best.

Mr. XXX is a patient with an amputation below the knee and has Medicare as his primary insurance payer. He is an amputee that has been progressing with activity and ambulation and with a proper fitting prosthesis with appropriate components he has the potential to be a K3 level functional amputee. This means that the patient has the ability or potential for ambulation with variable cadence and can tackle uneven terrain like curbs and stairs. This is typical of the community ambulator who has the ability traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic utilization beyond simple locomotion.

Medicare has become very specific in the documentation required for a new prosthesis or new prosthetic socket to be provided to beneficiaries. I have included a letter from Medicare for your review. Please conduct a prosthetic evaluation of Mr. XXX and document:

1) that the prosthesis does not fit and the prosthesis is in need of replacement

2) he is a K3 functional amputee

.

3) the types of activities that Mr. XXX engages in and wants to engage in with a proper fitting prosthesis

Mr. XXX conducts his daily activities like house chores and grocery shopping as well as interacting with his step children. There are few obstacles that will hold Mr. XXX back once he receives a well fitting prosthesis with appropriate components, but his biggest obstacle today is his current prosthesis. Mr. XXX states that he falls frequently as the socket fit is off and the prosthesis is not aligned appropriately for his current gait. These frequent falls are wearing on his body and they are becoming more frequent and "violent". By documenting these points of interest to Medicare it will help to meet the requirements of Medicare and allow him to be provided with the needed prosthetic device.

The prosthesis we recommend utilizes a shock absorber and torque absorber to reduce the pressures on his amputation and lower back/hip. The hydraulic ankle will allow for plantarflexion and dorsiflexion to allow for better gait and balance with stairs, ramps and hills. The foot I recommend is XXX with Vacuum suspension by XXX. If you agree with this prosthetic recommendation please record this as part of his prosthetic visit note in his chart.

If there are any questions regarding the needs of Mr. XXX or regarding the prosthetic recommendation, please do not hesitate to contact me. I appreciate your time and your understanding with these Medicare requirements and want to Thank You in advance for your help.

XXX, CPO, LPO

David Chapman, MD

Re: XXX - DOB: 03/18/1956

Thank you for referring our mutual patient, Ms. XXX to our office for evaluation and treatment of a right below knee amputation. Ms. XXX was seen and evaluated in our office on 06/05/2013 and I have attached a copy of our office clinical notes for your medical records.

In order to provide this service to Ms. XXX, our office is required by CMS to have a Detailed Prescription accompanying patient medical records to not only confirm this order, but also indicating that you concur with this prosthetic treatment plan. If you do agree with our recommendation, please review, sign and date the attached Detailed Prescription and return it to our office.

In addition, please provide any additional supporting documentation (examples that apply listed below) to justify the medical necessity as it relates to this plan of treatment, as many Insurance Companies and Medicare now require this documentation to be in our Supplier Records prior to proceeding and/or billing.

_X__ Physician's Clinical Documentation and Progress Notes

_X__Office/Hospital History and Physical

_X__Activity Level current and previous

_X__Brief Letter of Medical Necessity

Thank you for your valuable time and prompt attention to this request. We strive to provide the best quality patient care and timely delivery as possible. Once we have received the requested documentation, we will proceed according to the requirements set forth by Ms. XXX’s insurance plan. Please fax this requested documentation to our office at xxx-xxx-xxxx.

Should you have any questions or concerns, please do not hesitate to call our office and speak with me. Thank you in advance for understanding these demands placed on our patient care by the Payer.

XXX, CPO, LPO

Mr. XXX,

I spoke to you today regarding what is needed to get insurance authorization for your prosthesis. I apologize for the inconvenience and know it is frustrating, however, it is a requirement of your insurance and without the documentation, they will not pay for your prosthesis. Dr. XXX’s office has been very helpful and understands the required paperwork and documentation.

Please make an appointment with Dr. XXX to discuss your prosthetic needs as well as your daily, weekly and monthly activities. Dr. XXX must document what problems you are having with your current prosthesis and most important your goals and expected activity level with the new prosthesis. When I saw you last, we discussed that you wanted to be able to play with the grandkids, be active and more independent. I believe you have the ability to walk at different speeds, go outside, walk on uneven ground, play with the grandkids and so forth but this needs to be documented in Dr. XXX’s prosthetic evaluation visit notes.

When you go for your appointment, feel free to call me while you are there if any questions arise.

XXX, LPO, CPO

Attn: Terri, RN

Re: XXX

Hi Terri,

Thank you for taking time to speak with me Friday. I am attaching my notes from the prosthetic evaluation of Mr XXX. I am actually dropping his K-level (activity level) down to a K__ in order improve our authorization/policy compliance outcome. As we discussed the most important thing about the visit on Thursday with Mr. XXX is documenting his goals, current activity level and his potential activity level by listing the types of activities he can and plans to conduct. His insurance requires physician notes in regards to his need of a new prosthesis and his goals with the new prosthesis.

The description of a K-__ activity level according to Medicare is:

___________________________________________________

If you or Dr. XXX should have any questions while Mr XXX is in the office or anytime after please feel free to call me

Xxx-xxx-xxxx (office)

Xxx-xxx-xxxx (cell)

Thank you,

XXX, CPO, LPO

July 8, 2013

Dr XXX:

XXX was in today for a second prosthetic consultation in the last 3 months. His prosthesis has been causing him problems in both his gait and his back pain. The fit of the prosthesis is off and several adjustments have been attempted by his previous prosthetist according to Mr XXX.

Mr. XXX is a K3 Functional Level based on his past activities prior to his knee and shoulder injury in December. K3 means that Mr XXX has the ability or potential for ambulation with variable cadence and tackle uneven terrain like curbs and stairs. This is 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. Mr XXX is a transfemoral amputee and has Medicare as his primary insurance payer. Medicare has become very specific in the documentation required for a new prosthesis or new prosthetic socket to be provided to beneficiaries. I have included a letter from Medicare for your review.

Please conduct a prosthetic evaluation of Mr. XXX and document that the prosthesis is in need of replacement as well as the types of activities that Mr. XXX engages in or the types of activities he would like to engage in if his prosthesis was properly fitting and functioning. Also by documenting the low back and sound knee issues, that will help to illustrate the need for a new prosthesis as the current prosthesis caused the fall resulting in these injuries. By documenting the types of activities he engaged in prior to the fall and current prosthetic issues, it will show his potential to achieve a K3 functional level again. Without a properly fitting and functioning prosthesis Mr XXX will continue to experience stress on these problematic areas. By documenting this information it will help to meet the requirements of Medicare and allow him to be provided with the needed prosthetic device. The medical director of the Medicare replacement policy Mr XXX has denied the approval of the current prosthesis without this level of detailed documentation. He stated the records did not show that the patient is a K3 functional level ambulator and without the supporting documentation, they will either deny payment in its entirety or only consider him a K2 level prosthesis.

If there are any questions regarding the needs of Mr. XXX or the prosthetic recommendation, please do not hesitate to contact me. I appreciate your time and your understanding with these Medicare requirements and want to Thank You in advance for your help.

XXX, CPO, LPO

Physician Documentation request letter ◦ http://www.cgsmedic

are.com/jc/forms/pdf/JC_Physician_Documentation_Request_Letter.pdf

2011Dear Physician Letter ◦ https://www.cgsmedi

care.com/kyb/pubs/mb_J15/2011/10_2011/index.html#007

Freedom Website for MPK assistance ◦ Prosthetist resources

◦ http://www.freedom-innovations.com/assets/pdf/PlieReimbursementDocuments.Rev0713.pdf

Includes: ◦ Protocol for

Receiving Authorizations

◦ Prosthetic Evaluation Forms ROM and Strength

Residual Limb Health

◦ Sample Letters of Medical Necessity

◦ Literature Review

Aaron Sorensen, CPO, LPO, President OPBS asorensen@rhs-tn.com

Ph. 877-907-4180

Rob Cripe, VP Global Marketing rcripe@freedom-innovations.com Ph. 949-544-7916

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