Re: 5 year rule
Jim Thelen
Description
Collection
Title:
Re: 5 year rule
Creator:
Jim Thelen
Date:
7/2/2012
Text:
The query about the possible change of the 5 yr rule by medicare has
resulted in the following comments. My original question is followed by the
comments below. Thanks to all those who took the time to offer help. The
consensus was that there has been no change at this time.
Jim Thelen, CP, BOCO, LPO
Trinidad Medical Consultants
Dallas, TX
214-340-6200
Fax 214-340-2206
_____
Original question: Yesterday, I was told by a vendor that the Medicare 5
year rule for
> replacement of orthotic devices has been changed to 7 years. Can't find
> anything to substantiate that on Medicare website. Can anyone verify or
> refute that the rule is now 7 yrs or remains 5 yrs?
____________________________________________________________________________
__________
They may be confusing the time frame that patient
records, vendor invoices must be kept on file for audit purposes, we have
not heard any differant.
____________________________________________________________________________
__________
Would not shock me, but I have not seen anything regarding this! Seems that
they would have to justify a quality change in material studies to show a
longer useful lifetime, they should not be pulling this number out of thin
air. It has been related to the make up or construct of the item, this is
why many knee Orthoses are 3 years, not 5. They understand the rigors of
activity at the knee is greater than that associated with the spine.
____________________________________________________________________________
__________
I haven't seen a 7 year rule.
____________________________________________________________________________
__________
Here is what I have on the subject, including the most recent LCD Articles:
From the current Knee Orthoses LCD Article, effective July 2012
The following reflects the reasonable useful lifetime of prefabricated knee
orthoses:
L1810 - 1 year
L1820 - 1 year
L1830 - 1 year
L1831 - 2 years
L1832 - 2 years
L1836 - 3 years
L1843 - 3 years
L1845 - 3 years
L1850 - 2 years
The reasonable useful lifetime of custom fabricated orthoses is 3 years.
(Comment: This is only stated in the Knee Orthosis LCD Article, not the
AFO-KAFO which to my knowledge is still 5 years)
Replacement during the reasonable useful lifetime, is covered if the item
is lost or irreparably damaged. Replacement for other reasons, including but
not limited to irreparable wear, during the period of reasonable useful
lifetime is denied as noncovered. L-coded additions to knee orthoses (L2275
- L2830, K0672) will be denied as noncovered when the base orthosis is
noncovered.
From the current AFO-KAFO LCD, effective May 2012
Replacement of a complete orthosis or component of an orthosis due to loss,
significant change in the beneficiary's condition, or irreparable accidental
damage is covered if the device is still reasonable and necessary. The
reason for the replacement must be documented in the supplier's record.
The AFO-KAFO policy says nothing about wear and tear. Therefore the 5-year
rule applies.
PROSTHETICS
The Social Security Act was amended several year ago and the 5-year rule no
longer applies to Prosthetics.
Here are the requirements as stated in the LL Prosthesis LCD:
It is recognized that there are situations where the reason for replacement
includes but is not limited to: changes in the residual limb; functional
need changes; or irreparable damage or wear/tear due to excessive patient
weight or prosthetic demands of very active amputees.
Repairs to a prosthesis are covered when necessary to make the prosthesis
functional.
Replacement of a prosthesis or prosthetic component is covered if the
treating physician orders a replacement device or part because of any of the
following:
1. A change in the physiological condition of the patient; or
2. Irreparable wear of the device or a part of the device; or The condition
of the device, or part of the device, requires repairs and the cost of such
repairs would be more than 60% of the cost of a replacement device, or of
the part being replaced.
Replacement of a prosthesis or prosthetic components required because of
loss or irreparable damage may be reimbursed without a physician's order
when it is determined that the prosthesis as originally ordered still fills
the patient's medical needs. [Otherwise] Claims involving the replacement of
a prosthesis or major component (foot, ankle, knee, socket) must be
supported by a new physician's order.
Comment: So bottom line, if the prosthesis still works, still fits, meets
the patient's needs and functional levels, it cannot be replaced.
(Thank you Susan for you thorough comments. And to everyone else.)
Jim Thelen, CP, BOCO, LPO
Trinidad Medical Consultants
Dallas, TX
214-340-6200
Fax 214-340-2206
resulted in the following comments. My original question is followed by the
comments below. Thanks to all those who took the time to offer help. The
consensus was that there has been no change at this time.
Jim Thelen, CP, BOCO, LPO
Trinidad Medical Consultants
Dallas, TX
214-340-6200
Fax 214-340-2206
_____
Original question: Yesterday, I was told by a vendor that the Medicare 5
year rule for
> replacement of orthotic devices has been changed to 7 years. Can't find
> anything to substantiate that on Medicare website. Can anyone verify or
> refute that the rule is now 7 yrs or remains 5 yrs?
____________________________________________________________________________
__________
They may be confusing the time frame that patient
records, vendor invoices must be kept on file for audit purposes, we have
not heard any differant.
____________________________________________________________________________
__________
Would not shock me, but I have not seen anything regarding this! Seems that
they would have to justify a quality change in material studies to show a
longer useful lifetime, they should not be pulling this number out of thin
air. It has been related to the make up or construct of the item, this is
why many knee Orthoses are 3 years, not 5. They understand the rigors of
activity at the knee is greater than that associated with the spine.
____________________________________________________________________________
__________
I haven't seen a 7 year rule.
____________________________________________________________________________
__________
Here is what I have on the subject, including the most recent LCD Articles:
From the current Knee Orthoses LCD Article, effective July 2012
The following reflects the reasonable useful lifetime of prefabricated knee
orthoses:
L1810 - 1 year
L1820 - 1 year
L1830 - 1 year
L1831 - 2 years
L1832 - 2 years
L1836 - 3 years
L1843 - 3 years
L1845 - 3 years
L1850 - 2 years
The reasonable useful lifetime of custom fabricated orthoses is 3 years.
(Comment: This is only stated in the Knee Orthosis LCD Article, not the
AFO-KAFO which to my knowledge is still 5 years)
Replacement during the reasonable useful lifetime, is covered if the item
is lost or irreparably damaged. Replacement for other reasons, including but
not limited to irreparable wear, during the period of reasonable useful
lifetime is denied as noncovered. L-coded additions to knee orthoses (L2275
- L2830, K0672) will be denied as noncovered when the base orthosis is
noncovered.
From the current AFO-KAFO LCD, effective May 2012
Replacement of a complete orthosis or component of an orthosis due to loss,
significant change in the beneficiary's condition, or irreparable accidental
damage is covered if the device is still reasonable and necessary. The
reason for the replacement must be documented in the supplier's record.
The AFO-KAFO policy says nothing about wear and tear. Therefore the 5-year
rule applies.
PROSTHETICS
The Social Security Act was amended several year ago and the 5-year rule no
longer applies to Prosthetics.
Here are the requirements as stated in the LL Prosthesis LCD:
It is recognized that there are situations where the reason for replacement
includes but is not limited to: changes in the residual limb; functional
need changes; or irreparable damage or wear/tear due to excessive patient
weight or prosthetic demands of very active amputees.
Repairs to a prosthesis are covered when necessary to make the prosthesis
functional.
Replacement of a prosthesis or prosthetic component is covered if the
treating physician orders a replacement device or part because of any of the
following:
1. A change in the physiological condition of the patient; or
2. Irreparable wear of the device or a part of the device; or The condition
of the device, or part of the device, requires repairs and the cost of such
repairs would be more than 60% of the cost of a replacement device, or of
the part being replaced.
Replacement of a prosthesis or prosthetic components required because of
loss or irreparable damage may be reimbursed without a physician's order
when it is determined that the prosthesis as originally ordered still fills
the patient's medical needs. [Otherwise] Claims involving the replacement of
a prosthesis or major component (foot, ankle, knee, socket) must be
supported by a new physician's order.
Comment: So bottom line, if the prosthesis still works, still fits, meets
the patient's needs and functional levels, it cannot be replaced.
(Thank you Susan for you thorough comments. And to everyone else.)
Jim Thelen, CP, BOCO, LPO
Trinidad Medical Consultants
Dallas, TX
214-340-6200
Fax 214-340-2206
Citation
Jim Thelen, “Re: 5 year rule,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/233796.
