Post surgical Prosthesis or Definitive? Part IV
Jeremy Sprouse
Description
Collection
Title:
Post surgical Prosthesis or Definitive? Part IV
Creator:
Jeremy Sprouse
Date:
3/8/2013
Text:
Sorry for so many posts.I kept getting them returned for being too long..so
I had to divide them up. I hope everyone has a great weekend.
Hi, Jeremy,
You can try this, but I would not expect to get paid for both. In the
probable denial letter you will likely hear much the same thing as if an AFO
did not last the minimum of five years (assuming no change in medical
condition) - the patient was not provided with the appropriate device
initially if this change was necessary. Maybe unfortunately, but at least
with Medicare, every code used has to be justified as medically necessary,
and some kind of fitting to determine the final activity level is not a
medical justification. You will have to assign a K-Level for the foot of
the initial fitting in any case, and if you made this kind of a change, you
would most likely have to document a change in condition to justify the
prosthesis change (K1 or K2 to K3 or K4, and a change in activity level is
not usually a change in condition), and further demonstrate why that change
could not have been reasonably anticipated. For a time, and perhaps even
now, you would received an initial denial, but could usually get paid if you
documented why the patient needed a preparatory, and there were reasons that
were accepted, such as major fluid retention problems that were expected to
resolve, or co-morbidities that were concurrently undergoing rehab, but the
last few times I did this, they were never paid for, so we discontinued the
practice, and instead did what you normally do: definitive prosthesis and
socket changes.
This is an unfortunate side of the potential in the K-Level descriptions,
and we can't have it both ways. Somewhat ironically, one of the original
reasons for the potential was to try and avoid the very situation you are
proposing, which led to many complete prosthesis changes within the first
year, and to encourage better initial evaluations. That was my common
practice when I first came into the field (pre-K-Level), and both were
always paid for then. As with you, I thought that rather wasteful, but
there are multiple ways to think about this, and I have seen many of both.
On the one hand, many patients, even younger ones, appear to do better to
have a simple, lightweight prosthesis for their early ambulation, rather
than having their initial learning on a more sophisticated and heavier
prosthesis that would actually be ideal for them 6-12 months later. On the
other hand, we are then making a significant change in the design, most
likely in the first year, that the patient will then have to adapt to. This
last does not particularly concern me, as very few of my prosthetic patients
have appeared to have a problem adapting, and most of those who did were
actually better off long-term with a design very much like the first one.
At some point we have to get serious about our evaluation skills, and make
good calls early, understanding that what is ideal for a patient the first
month is not the same as in six months, but accepting some early
inefficiency. The AMP and other physical evaluation tools can be very
helpful with this.
As another example, I have a patient currently who has no insurance and will
be hitting his retirement account to pay for his prosthesis. This
prosthesis will have to work well for him until he can go on Medicare
disability (2 years lead time). He would have no interest in a prep
prosthesis/definitive combo when he is paying himself, and he assumed that I
could evaluate him sufficiently to make a good call from the start. I do
not consider that unreasonable. If I couldn't come up with a design that
would serve him well for two years, I might wonder if I was in the wrong
field. It does not have to be perfect, but it ought to be good. He is not
particularly old, and relatively active, and most any competent prosthetist
should be able to come up with something that would function well. It is
highly likely that in six months I may second guess myself regarding the
chosen foot, but that will be at the fine detail level, not the level of
basic function. If the basic function of the prosthesis turned out to be a
poor match in six months, all I would need was a mirror to understand the
problem.
The real problem you mention, that of documenting the functional level, is
just a problem, and Medicare's current approach is beyond absurd. I have a
few times done a variation of what you are suggesting, but that means eating
significant expense. The only purchased things are a SACH foot, a
suspension sleeve, and some materials, it uses a thermoplastic socket (which
I rarely use for definitives), and the patient is set up with what is called
a prototype prosthesis but what in reality is a preparatory prosthesis. The
patient uses the prosthesis for 2-4 months, at the end of which we should
have a good view of the likely definitive functional level. As a bonus,
most of the early limb reduction will have already happened, so the first
definitive socket will usually fit well for a longer period. One
significant downside is that we are not getting paid anything for all of
this extra work, except possibly less expense in time dealing with audits.
Another is that the prosthesis does not look like much (too many people have
seen Oscar), and it seems that someone will always ask where they got their
prosthesis, and they hear I got it from James, a less than ideal
advertisement for my practice.
But even then, they are still your comments in your notes about how they are
functioning, and to the audit folks that is not enough, so even if you went
through the sequence you are proposing, and it worked exactly as you would
like it to, I am not sure what has been gained. Their position is somewhat
understandable, because there has in fact been a great deal of fraud in our
field relating to functional level. A number of years ago a clinician from
a particular P&O company told me that for them, Every patient has potential
for a Pathfinder, and he wasn't joking. 20 years old, 80 years old, it
didn't matter. They received Pathfinders. And how many of us have seen
quite elderly patients ambulating stiff-legged with their walkers on C-Legs.
Someone is providing these, and somehow justifying it. Most of our wounds
are self-inflicted.
Sorry about the digression, and I appreciate your desire to do what is best
for your patients and try and keep Medicare happy at the same time, an
increasingly difficult task. Best of luck.
------------------------------------------------------------------
Jeremy Sprouse CPO
I had to divide them up. I hope everyone has a great weekend.
Hi, Jeremy,
You can try this, but I would not expect to get paid for both. In the
probable denial letter you will likely hear much the same thing as if an AFO
did not last the minimum of five years (assuming no change in medical
condition) - the patient was not provided with the appropriate device
initially if this change was necessary. Maybe unfortunately, but at least
with Medicare, every code used has to be justified as medically necessary,
and some kind of fitting to determine the final activity level is not a
medical justification. You will have to assign a K-Level for the foot of
the initial fitting in any case, and if you made this kind of a change, you
would most likely have to document a change in condition to justify the
prosthesis change (K1 or K2 to K3 or K4, and a change in activity level is
not usually a change in condition), and further demonstrate why that change
could not have been reasonably anticipated. For a time, and perhaps even
now, you would received an initial denial, but could usually get paid if you
documented why the patient needed a preparatory, and there were reasons that
were accepted, such as major fluid retention problems that were expected to
resolve, or co-morbidities that were concurrently undergoing rehab, but the
last few times I did this, they were never paid for, so we discontinued the
practice, and instead did what you normally do: definitive prosthesis and
socket changes.
This is an unfortunate side of the potential in the K-Level descriptions,
and we can't have it both ways. Somewhat ironically, one of the original
reasons for the potential was to try and avoid the very situation you are
proposing, which led to many complete prosthesis changes within the first
year, and to encourage better initial evaluations. That was my common
practice when I first came into the field (pre-K-Level), and both were
always paid for then. As with you, I thought that rather wasteful, but
there are multiple ways to think about this, and I have seen many of both.
On the one hand, many patients, even younger ones, appear to do better to
have a simple, lightweight prosthesis for their early ambulation, rather
than having their initial learning on a more sophisticated and heavier
prosthesis that would actually be ideal for them 6-12 months later. On the
other hand, we are then making a significant change in the design, most
likely in the first year, that the patient will then have to adapt to. This
last does not particularly concern me, as very few of my prosthetic patients
have appeared to have a problem adapting, and most of those who did were
actually better off long-term with a design very much like the first one.
At some point we have to get serious about our evaluation skills, and make
good calls early, understanding that what is ideal for a patient the first
month is not the same as in six months, but accepting some early
inefficiency. The AMP and other physical evaluation tools can be very
helpful with this.
As another example, I have a patient currently who has no insurance and will
be hitting his retirement account to pay for his prosthesis. This
prosthesis will have to work well for him until he can go on Medicare
disability (2 years lead time). He would have no interest in a prep
prosthesis/definitive combo when he is paying himself, and he assumed that I
could evaluate him sufficiently to make a good call from the start. I do
not consider that unreasonable. If I couldn't come up with a design that
would serve him well for two years, I might wonder if I was in the wrong
field. It does not have to be perfect, but it ought to be good. He is not
particularly old, and relatively active, and most any competent prosthetist
should be able to come up with something that would function well. It is
highly likely that in six months I may second guess myself regarding the
chosen foot, but that will be at the fine detail level, not the level of
basic function. If the basic function of the prosthesis turned out to be a
poor match in six months, all I would need was a mirror to understand the
problem.
The real problem you mention, that of documenting the functional level, is
just a problem, and Medicare's current approach is beyond absurd. I have a
few times done a variation of what you are suggesting, but that means eating
significant expense. The only purchased things are a SACH foot, a
suspension sleeve, and some materials, it uses a thermoplastic socket (which
I rarely use for definitives), and the patient is set up with what is called
a prototype prosthesis but what in reality is a preparatory prosthesis. The
patient uses the prosthesis for 2-4 months, at the end of which we should
have a good view of the likely definitive functional level. As a bonus,
most of the early limb reduction will have already happened, so the first
definitive socket will usually fit well for a longer period. One
significant downside is that we are not getting paid anything for all of
this extra work, except possibly less expense in time dealing with audits.
Another is that the prosthesis does not look like much (too many people have
seen Oscar), and it seems that someone will always ask where they got their
prosthesis, and they hear I got it from James, a less than ideal
advertisement for my practice.
But even then, they are still your comments in your notes about how they are
functioning, and to the audit folks that is not enough, so even if you went
through the sequence you are proposing, and it worked exactly as you would
like it to, I am not sure what has been gained. Their position is somewhat
understandable, because there has in fact been a great deal of fraud in our
field relating to functional level. A number of years ago a clinician from
a particular P&O company told me that for them, Every patient has potential
for a Pathfinder, and he wasn't joking. 20 years old, 80 years old, it
didn't matter. They received Pathfinders. And how many of us have seen
quite elderly patients ambulating stiff-legged with their walkers on C-Legs.
Someone is providing these, and somehow justifying it. Most of our wounds
are self-inflicted.
Sorry about the digression, and I appreciate your desire to do what is best
for your patients and try and keep Medicare happy at the same time, an
increasingly difficult task. Best of luck.
------------------------------------------------------------------
Jeremy Sprouse CPO
Citation
Jeremy Sprouse, “Post surgical Prosthesis or Definitive? Part IV,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 6, 2024, https://library.drfop.org/items/show/234874.
