K0-K4 level documentation for DMe RAC appeal.

K0-K4 level documentation for DMe RAC appeal.

Padmavathi S. Annaldasula

5/7/2013

Hi,

 

I am working on an RAC audit for the lower limb prosthesis. We billed the
codes with a K3 modifier and per the MLN SE1213 & LCD L11442 both state when
determining the potential functional level, suppliers and the referring
physicians must take into account the beneficiary's history, current overall
medical condition, and desire to walk. The supplier then uses a modifier on
the claim to indicate the beneficiary's potential functional level (K0 to
K4).

 

Prostheses are not considered medically necessary if the beneficiary has the
lowest potential functional level (K0), which indicates that he or she does
not have the ability or the potential to walk. In addition, for some
prostheses, the local coverage determination specifies the minimum potential
functional level that the beneficiary must have for the prosthesis to be
considered medically necessary.

 

 

Level 3: Has the ability or potential for ambulation with variable candence.
Typical of community ambulatory who has the ability to traverse most
environmental barriers and may have vocational, therapeutic, or exercise
activity that demands prosthetic utilization beyond simple locomotion.

 

So how do I support this thru medical documentation. I have the op rpts
showing the above the knee amputation but what else should I be looking for
in the notes to support the K3 modifier. Any help would be great.

 

Thanks,

Padma Annaldasula CPC