Replies: Post surgical Prosthesis or Definitive? Part III
Jeremy Sprouse
Description
Collection
Title:
Replies: Post surgical Prosthesis or Definitive? Part III
Creator:
Jeremy Sprouse
Date:
3/8/2013
Text:
Jeremy,
When I was in private practice I almost always provided the definitive
prosthesis as the initial prosthesis and then billed for socket replacements
as they became medically necessary. It was only when a clinic or specific
physician would order and insist on a preparatory that I would provide one.
This was due in part to the componentry limitations set by CMS rules on a
preparatory prosthesis irregardless of functional level; in part due to
patient gait training, retraining considerations. My rationale was that
gait training a new patient on one set of components, usually less
functional componentry per CMS limitations; then turning around 3; or 6; or
9; or 12 months later and reintroducing a whole new set of componentry,
usually higher functioning componentry allowed for a definitive and based on
K level, actually set the patients progress back. The longer the time
between the preparatory and the definitive the more gait retraining was
usually required. As far as cost; it was a wash. A definitive with socket
replacement typically billed out about the same as a preparatory and
definitive combination. I don't believe there is a minimum time frame
between a preparatory and a definitive as much as a need to document medical
necessity and the appropriateness of the changes that are to be made. You
are correct though, providing the preparatory first might very well provide
a documented history for justification of a K level determination, but then
they are no longer a new patient. The best approach with new patients is
using one of the amputee mobility predictors that are available and basing
the K level justifications on that.
Will be interested in the consensus ...
-----------------------------------------------------------------------
Jeremy
I have billed legs both ways. With my previous employer we used to do
preparatory leg with a generic foot and then 3-6 months later after there
leg has decreased in size and we know there activity level we make a
definitive prosthesis. At my current office, we do more definitive legs with
socket replacement. I understand what you mean about trying to figure out
how active they are going to be. Currently, we are using the AmpPro and
AmpnoPro tests to determine the patients functional level and that will
justify what we are making. If we feel that the patients K-level later
changes we can have the test performed again and document it. I did price
comparison on billing a prep leg and a definitive against a definitive with
socket changes and it comes out pretty equal. I think that there are pro's
and con's with both ways, and each patient should be decided individually.
Hope this helps
----------------------------------------------------------------------------
Please post your responses. I think this a question that many of us have.
Personally I have gone back and forth on this and don't have a clear idea on
what to do here. Most recently I have been fitting definitive and doing
socket replacements, however I have heard from others that say we still need
to be doing Prep codes and moving into definitive on the socket prosthesis.
So I am very interested to hear what you find out.
----------------------------------------------------------------------------
------
Jeremy,
At our office we do a simple mod-PE socket if you will, set inside of a
knee-immobilizer for the healing stage. This is billed with L5450. After
healing we bill L5540 for the prep prosthesis. Our patients are typically
in their prep prosthesis for 6 months to a year. I am not sure about
minimum time between prep and definitive but I've had a couple patients go
from 0ply to 25ply in a matter of 3 months. My incredible shrinkers I
called them. :) I just made sure to document the heck out of everything
with these patients and had a ton of measurements for each. We didn't have
a problem with either of their insurances moving on to the definitive so
soon.
----------------------------------------------------------------------------
------
Hello Jeremy.
At our practice we bill for a temporary prosthesis with a K2 foot, then 3-6
months down the road we bill for definitive prosthesis with a potentially
higher K leve. That way the patient ends up having a secondary prothesis.
Hope this helps.
----------------------------------------------------------------------------
-------
The funtion level is determined by the Physician and clinicals should be
obtained so that you can place the appropiate level on the patient as per
the doctor. Medicare does not look at the Practitioners notes to determine
what level was appropriate.
Also some BCBS will not cover for a prep leg as well just FYI.
Typically it is around 6-8 months to be able to bill for the definative.
The O and P Edge magazine has an article in there regarding billing
----------------------------------------------------------------------------
----
We do not bill prepatories for the very reason you noted. It does not
benefit a K3 patient to take gait training with a sach & then have to use a
K3 foot with no instruction. I use the amputee's current functional
abilities- Can they hop with a walker & how far? Can they hop using the
parallel bars? Can they independently sit to stand? Can they stand on one
leg for 3+ minutes? I then use the functional assessment of overall
strength- upper limb strength, residual limb strength, etc. I strongly
document the patient's pre-amputation status and am very specific with those
activities- X# months prior to amputation, pt walked independently within
community daily. She walked through Walmart for 45 minutes while shopping,
she walked X# feet from the parking lot into church X# times per week, she
walked her dog around the block daily. She performed all of these duties
with no ambulatory assistive aids. I then assure this info is written in
the MD notes and that we both agree in written notes on the POTENTIAL
K-level by stating Based on the above noted facts, patient's potential
K-level is....
I am fairly familiar with Medicare policy and I have never seen a documented
time frame between prep & definitive. That's not to say there isn't one.
Because we don't bill preps, I do not stay current on that section of the
policy.
========
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should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
When I was in private practice I almost always provided the definitive
prosthesis as the initial prosthesis and then billed for socket replacements
as they became medically necessary. It was only when a clinic or specific
physician would order and insist on a preparatory that I would provide one.
This was due in part to the componentry limitations set by CMS rules on a
preparatory prosthesis irregardless of functional level; in part due to
patient gait training, retraining considerations. My rationale was that
gait training a new patient on one set of components, usually less
functional componentry per CMS limitations; then turning around 3; or 6; or
9; or 12 months later and reintroducing a whole new set of componentry,
usually higher functioning componentry allowed for a definitive and based on
K level, actually set the patients progress back. The longer the time
between the preparatory and the definitive the more gait retraining was
usually required. As far as cost; it was a wash. A definitive with socket
replacement typically billed out about the same as a preparatory and
definitive combination. I don't believe there is a minimum time frame
between a preparatory and a definitive as much as a need to document medical
necessity and the appropriateness of the changes that are to be made. You
are correct though, providing the preparatory first might very well provide
a documented history for justification of a K level determination, but then
they are no longer a new patient. The best approach with new patients is
using one of the amputee mobility predictors that are available and basing
the K level justifications on that.
Will be interested in the consensus ...
-----------------------------------------------------------------------
Jeremy
I have billed legs both ways. With my previous employer we used to do
preparatory leg with a generic foot and then 3-6 months later after there
leg has decreased in size and we know there activity level we make a
definitive prosthesis. At my current office, we do more definitive legs with
socket replacement. I understand what you mean about trying to figure out
how active they are going to be. Currently, we are using the AmpPro and
AmpnoPro tests to determine the patients functional level and that will
justify what we are making. If we feel that the patients K-level later
changes we can have the test performed again and document it. I did price
comparison on billing a prep leg and a definitive against a definitive with
socket changes and it comes out pretty equal. I think that there are pro's
and con's with both ways, and each patient should be decided individually.
Hope this helps
----------------------------------------------------------------------------
Please post your responses. I think this a question that many of us have.
Personally I have gone back and forth on this and don't have a clear idea on
what to do here. Most recently I have been fitting definitive and doing
socket replacements, however I have heard from others that say we still need
to be doing Prep codes and moving into definitive on the socket prosthesis.
So I am very interested to hear what you find out.
----------------------------------------------------------------------------
------
Jeremy,
At our office we do a simple mod-PE socket if you will, set inside of a
knee-immobilizer for the healing stage. This is billed with L5450. After
healing we bill L5540 for the prep prosthesis. Our patients are typically
in their prep prosthesis for 6 months to a year. I am not sure about
minimum time between prep and definitive but I've had a couple patients go
from 0ply to 25ply in a matter of 3 months. My incredible shrinkers I
called them. :) I just made sure to document the heck out of everything
with these patients and had a ton of measurements for each. We didn't have
a problem with either of their insurances moving on to the definitive so
soon.
----------------------------------------------------------------------------
------
Hello Jeremy.
At our practice we bill for a temporary prosthesis with a K2 foot, then 3-6
months down the road we bill for definitive prosthesis with a potentially
higher K leve. That way the patient ends up having a secondary prothesis.
Hope this helps.
----------------------------------------------------------------------------
-------
The funtion level is determined by the Physician and clinicals should be
obtained so that you can place the appropiate level on the patient as per
the doctor. Medicare does not look at the Practitioners notes to determine
what level was appropriate.
Also some BCBS will not cover for a prep leg as well just FYI.
Typically it is around 6-8 months to be able to bill for the definative.
The O and P Edge magazine has an article in there regarding billing
----------------------------------------------------------------------------
----
We do not bill prepatories for the very reason you noted. It does not
benefit a K3 patient to take gait training with a sach & then have to use a
K3 foot with no instruction. I use the amputee's current functional
abilities- Can they hop with a walker & how far? Can they hop using the
parallel bars? Can they independently sit to stand? Can they stand on one
leg for 3+ minutes? I then use the functional assessment of overall
strength- upper limb strength, residual limb strength, etc. I strongly
document the patient's pre-amputation status and am very specific with those
activities- X# months prior to amputation, pt walked independently within
community daily. She walked through Walmart for 45 minutes while shopping,
she walked X# feet from the parking lot into church X# times per week, she
walked her dog around the block daily. She performed all of these duties
with no ambulatory assistive aids. I then assure this info is written in
the MD notes and that we both agree in written notes on the POTENTIAL
K-level by stating Based on the above noted facts, patient's potential
K-level is....
I am fairly familiar with Medicare policy and I have never seen a documented
time frame between prep & definitive. That's not to say there isn't one.
Because we don't bill preps, I do not stay current on that section of the
policy.
========
********************
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
Jeremy Sprouse, “Replies: Post surgical Prosthesis or Definitive? Part III,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 7, 2024, https://library.drfop.org/items/show/234889.
