Contracture Reduction Orthosis-Medicare reimbursemet
Randy McFarland
Description
Collection
Title:
Contracture Reduction Orthosis-Medicare reimbursemet
Creator:
Randy McFarland
Date:
11/17/2005
Text:
ORIGINAL QUESTION
I am considering providing a dynamic (spring loaded joints) KAFO for a
non ambulatory 41 year old spinal cord injured patient who is developing
knee and ankle contractures which are ~30 degrees flexion.
Have any of you had problems getting Medicare to acknowledge the
medical necessity of such an orthosis?
Thanks,
Randy McFarland, CPO
Fullerton, CA
RESPONSES
In our region, DMERC D, medicare does not recognize the spring loaded
joint as a covered item. At this point, it does not matter how much
documentation you have, they will not pay us. I don't know what region
you are in, but I would look in the medicare manual. Hope this helps,
although I know it is not the answer you were looking for.
Medicare will not cover a KAFO for a non-ambulatory patient.
They will pay for contracture management equipment on a rental basis
(i.e. Dynasplint or Empi).
I cannot remember the details of the several cases but I do
recall some points of interest.I believe according to Medicare that the
patient must have a potential
for ambulation.Medicare considers a contracture' to be a fixed skeletal
deformity but
lack of muscle elongation is a soft tissue condition and treatable.
Either consult the Ultraflex catalog for the correct medical terminology
or call Ultraflex, Bill or other members of customer service are most
helpful. Medicare will not cover Ultraflex's concentric joint power
units even
though, in my opinion, they are the best available.
Avoid using 718.4 joint contracture as Medicare considers this to be
fixed and not correctible and will deny. Also, instead of using L2999
for the concentric spring loaded joint, you could consider using L2210,
dorsiflexion assist.
I would call Medicare directly and ask this question. My understanding
is that a patient must have the potential to ambulate to have medicare
cover any leg braces or leg prosthesis.
I just went through a hearing on an upper extremity orthosis
(Ultraflex). The hearing officer said that Medicare is looking much
more carefully at these devices. One of the main things they are
looking at is whether the patient is getting adequate PT prior to the
decision to use the device. Although that should not be our
responsibility, Medicare is making it so. I asked if I was supposed to
question the doctor prescribing the device about the validity of the
prescription and she basically said yes. I couldn't get any feedback
regarding how much PT they thought was adequate.
I did get positive results from my hearing and the officer indicated
that it was due to the positive interaction I had with both the
physician
and the therapist prior to providing the device. I suspect that, if I
had not been able to show, in writing, that we had discussed the need
for the device and options, the outcome would have been less than
positive. She also indicated that positive outcomes of the device
documented by both myself and the patient's OT influenced her decision.
So my advice would be to make sure that you are working closely with
the
patient's therapist and physician and document everything.
Medicare does not pay for dynamic contracture assisted devices for a
purchase item. The only pay for them as rental items like a dynasplint.
I would consider using a step up or step lock design if you want to
receive reimbursement for your joints.
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I am considering providing a dynamic (spring loaded joints) KAFO for a
non ambulatory 41 year old spinal cord injured patient who is developing
knee and ankle contractures which are ~30 degrees flexion.
Have any of you had problems getting Medicare to acknowledge the
medical necessity of such an orthosis?
Thanks,
Randy McFarland, CPO
Fullerton, CA
RESPONSES
In our region, DMERC D, medicare does not recognize the spring loaded
joint as a covered item. At this point, it does not matter how much
documentation you have, they will not pay us. I don't know what region
you are in, but I would look in the medicare manual. Hope this helps,
although I know it is not the answer you were looking for.
Medicare will not cover a KAFO for a non-ambulatory patient.
They will pay for contracture management equipment on a rental basis
(i.e. Dynasplint or Empi).
I cannot remember the details of the several cases but I do
recall some points of interest.I believe according to Medicare that the
patient must have a potential
for ambulation.Medicare considers a contracture' to be a fixed skeletal
deformity but
lack of muscle elongation is a soft tissue condition and treatable.
Either consult the Ultraflex catalog for the correct medical terminology
or call Ultraflex, Bill or other members of customer service are most
helpful. Medicare will not cover Ultraflex's concentric joint power
units even
though, in my opinion, they are the best available.
Avoid using 718.4 joint contracture as Medicare considers this to be
fixed and not correctible and will deny. Also, instead of using L2999
for the concentric spring loaded joint, you could consider using L2210,
dorsiflexion assist.
I would call Medicare directly and ask this question. My understanding
is that a patient must have the potential to ambulate to have medicare
cover any leg braces or leg prosthesis.
I just went through a hearing on an upper extremity orthosis
(Ultraflex). The hearing officer said that Medicare is looking much
more carefully at these devices. One of the main things they are
looking at is whether the patient is getting adequate PT prior to the
decision to use the device. Although that should not be our
responsibility, Medicare is making it so. I asked if I was supposed to
question the doctor prescribing the device about the validity of the
prescription and she basically said yes. I couldn't get any feedback
regarding how much PT they thought was adequate.
I did get positive results from my hearing and the officer indicated
that it was due to the positive interaction I had with both the
physician
and the therapist prior to providing the device. I suspect that, if I
had not been able to show, in writing, that we had discussed the need
for the device and options, the outcome would have been less than
positive. She also indicated that positive outcomes of the device
documented by both myself and the patient's OT influenced her decision.
So my advice would be to make sure that you are working closely with
the
patient's therapist and physician and document everything.
Medicare does not pay for dynamic contracture assisted devices for a
purchase item. The only pay for them as rental items like a dynasplint.
I would consider using a step up or step lock design if you want to
receive reimbursement for your joints.
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Randy McFarland, “Contracture Reduction Orthosis-Medicare reimbursemet,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/225694.
