Policy and Documentation for K3 Prosthetic Patients
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PRESENTED BY: Aaron Sorensen, MBA, CPO, LPO O and P Billing Solutions, Inc.
Transcript of Policy and Documentation for K3 Prosthetic Patients
PRESENTED BY:
Aaron Sorensen, MBA, CPO, LPO
O and P Billing Solutions, Inc.
General Medicare Coverage Guideline
General Lower Extremity Prosthetic Policy
Understanding your LCDs
◦Evaluation of patient
Pre-prosthetic treatment
◦Know your region’s audit pattern
The records must document the patient'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.
Medicare considers every amputee K2 and medical documentation is required to support ALL functional levels.
K3 and K4 functional levels must be clearly documented; past history, current status or potential
LCDs ◦ Local coverage
Determination
◦ States the intent of the coverage language of beneficiary’s coverage for medical necessity
◦ Defines functional levels, K-levels
Understand Both: ◦ Written Policy ◦ Interpretation!!!!
This is where the auditors and medical director may vary
Prepare for interpretation BUT cover written 100% ◦ With ALJ and appeal
levels you are arguing written LCD
K3 is today’s focus
Level 3: 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.
Pre-prosthetic consultation ◦ Before generating a
detailed Rx (L-codes) ◦ Gather
documentation PTs
MDs Specialists
PCP
Up to two years history
What picture does it paint????
Picture painted? ◦ Full spectrum
shows…?
◦ What gaps need filling based on your assessment?
◦ What info is in the documentation you were not aware of?
◦ Does not affect K-level or LCD policy?
How do you fill gaps in paperwork? ◦ Schedule appointment(s)
with physician for additional/current assessment
◦ Explain why there is difference (current vs past) in medical notes
◦ Schedule a PT assessment for current info
◦ Discuss potential!!! Must back up the projection
with supporting documentation
Make your assessment easily understood to referral sources before these appointments
Be available to attend these appointments
Your assessment communicated to referral sources ◦ Components by name ◦ Justification for each
component or L-code ◦ Suspension needed
NOT LCD functional level controlled
◦ Request this info be included in the medical documentation for the prosthetic treatment plan
Know your region’s audit pattern ◦ Region D
L5987 94% were denied
Top reasons included documentation did not support functional level
The L5981 review involved improper payment rate of 75.99%.
Region A Historical Review Results A widespread complex medical
review was performed for Lower Limb Prostheses HCPCS codes billed with a K3 functional level modifier and components/additions provided. This review resulted in a Charge Denial Rate (CDR) of 50.1%.
A summary of findings were published on the NHIC, Corp. Website on April 24, 2014. Based on this result, a widespread prepayment review was continued.
Attend pt appointments with physician and therapist
Take pictures Keep invoices organized Take video Have patient write
testimonial Get attestations ◦ Patient ◦ Physician ◦ Therapist ◦ Activity organizers
Know resources to tap ◦ Freedom website ◦ http://www.freedom-
innovations.com/prosthetist/
Receive CMS e-mail blasts
◦ Check your region website
◦ http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/index.html?redirect=/MLNMattersArticles/
Attend CMS sponsored meetings ◦ Keep printed materials for appeal
purposes
Attend O and P meetings; local, state, regional, national
Aaron Sorensen, CPO, LPO, President OPBS [email protected]
Ph. 877-907-4180
Rob Cripe, VP Global Marketing [email protected] Ph. 949-544-7916
Freedom Innovations thanks you for your continued support and hopes this series of webinars helps you navigate the tumultuous environment of serving MEDICARE PATIENTS.
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Next webinar: September 26
Topic: High Tech Prosthetics
