Preventing Denials for Lower Limb Prosthesis

The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:

Reasons for Denial – Insufficient Documentation

For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.

For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s medical condition(s) that requires the use of the specifically ordered lower limb prosthetic as well as beneficiary’s medical condition(s) that would impact the beneficiary’s ability to effectively utilize the specifically ordered lower limb prosthetic in achieving a defined functional state. The medical record is not limited to physician’s office records but may include:

• The ordering provider must sign and date a prescription that includes the diagnosis, prognosis, and length of time the patient requires the item
• Records from hospitals, nursing facilities, home health agencies, or other health care professionals

The Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) received a high volume of submitted claims for lower limb prosthetic covers and protective covering systems for the same lower limb prosthesis. The need for both of these is rare. (For details refer to http://www.aopanet.org/codingreimbursement/coding-issues .)

To Prevent Denials

A medical necessity determination for certain components/additions to the prosthesis is based on the beneficiary’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 beneficiary’s past history (including prior prosthetic use if applicable)
• The beneficiary’s current condition including the status of the residual limb and the nature of other medical problems
• The beneficiary’s desire to ambulate

Base clinical assessments of beneficiary rehabilitation potential on the following classification levels:

• Level 0: 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
• Level 1: 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)
• Level 2: 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)
• Level 3: Has the ability or potential for ambulation with variable cadence (typical of the community ambulatory who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion)
• Level 4: 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)

The records must contain documentation on 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.

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