Re: Prosthetic K Level vs Powered Wheel Chair

Re: Prosthetic K Level vs Powered Wheel Chair

Rachel Hartsell

5/14/2013

Here is the original post:
Dear List,
I have a 48 year old patient who is in need of a new prosthesis due to
weight gain and she has Medicare. In our office, she is able to
display that she is a K3 level ambulator and does not use any
assistive device. My potential problem is that she also has a
powerchair that she received about a year ago, and we have been told
that Medicare is cross-referencing claims.

I have talked to a PT and she gave me the power wheel chair evaluation
and explained to me her process. In it, some of the questions
include: what is the pt's mobility limitation and how does it
interfere with the performance of ADL's? why can't a cane or walker
meet this pt's mobility needs? how far can the pt ambulate without
stopping? what has changed to now require the use of a power
mobility device? etc. Per the PT, her goal is to prove that the pt
cannot safely and consistently ambulate at least 10 meters (25 feet).

As far as I can tell, if the pt meets the criteria for a powerchair
(and Medicare retains these records for about 5 years to cross
reference claims), then it obviously will contradict my evaluation
that she is a K3 level ambulator. The pt states that she needs the
chair because her arthritis acts up in her sound side knee when it
rains and makes it difficult to get around on those days. Medicare is
not going to care that she only uses it a few days a month. As far as
they are concerned, she cannot ambulate safely for 25 feet.

Has anyone run into a problem with Medicare and K2 or K3 with a pt who
has a powerchair?

I just want to get her taken care of and do my best to avoid a huge
audit. If I had my way, I would put her in a K3 foot and fight the
audit tooth and nail, but if I can try to avoid that, I will.

Thanks in advance.

Rachel Hartsell, CPO, LPO
Spears Prosthetics and Orthotics
Memphis, TN


Responses:
-An orthotist stated that she had a pt who drove to her office and
ambulated with a walker. He needed a knee brace which they provided,
but it got denied by Medicare because the pt has a powerchair and the
reason was that he is not ambulatory, but he clearly was. They are
fighting this.
-Several responses to do a socket replacement only.
-Several responses to have her sign a waiver/ABN, and possibly have
her pay upfront.
-One person said that Medicare paid for a prosthesis, but then audited
it and re-couped the entire claim because the pt has a powerchair.
The prosthetist did not know the pt had one, and they are fighting
this.
-One said that if a pt has a powerchair, it will be a 100% chance of
an audit, regardless of yours and the MD's documentation. They
suggested that we ask if the chair was filed to Medicare, or if
Medicare pays for the maintenance for the chair. They said that if
Medicare does not know about the chair, then we should be ok. Even if
Medicare denied the chair, they know that the pt is wanting one and it
could still flag our claim.
-One person said that once a claim is in the audit process, which
could takes months to even years, we cannot bill for any replacement
items either, like liners or socks. They also said that since the
chair was billed first, it is our field that will be audited and have
to pay back money, not the chair company.
-One person went to the AAOP meeting in February and spoke with Zita
Upchurch. He quoted the meeting in which they said that If a pt
qualifies for a powerchair, they cannot also qualify for a
prosthesis. He said that Medicare is looking for any justification
or co-morbidity to downgrade a pt's K-level.


My response to all of this. I spoke with our billing agent, and she
said that we recently billed for bilateral BK prostheses on a pt, and
got paid, even though the pt has a powerchair. We knew about the
chair in advance, and fit the pt with K1 components only. As far as I
can tell, Medicare will still pay for a prosthesis for TRANSFER
PURPOSES ONLY, K1. The pt has to be able to get into the chair. On
the flip side, they will NOT pay for a lower extremity orthosis for
transfers, and if they have a powrechair, Medicare deems them as
non-ambulatory regardless of documentation, including video, on the
contrary. For the pt that I originally referenced, I will be doing a
socket replacement onlyand list that it is to help her transfer. It
seems like my hands are tied, but it is the only way to help the pt.
It still may flag an audit, but it will be easier to justify the
replacement then either a K2 or K3 foot given that she has a
powerchair. I'm going with her to her doctor's appt later this month
to start getting documentation before I start anything.

We all need to ask each and every pt that we treat if they have a
chair and who paid for it. We also need to educate the MD's and PT's
that if they help a pt get a powerchair, they will not be able to get
an orthosis, and will be able to only (maybe) get a K1 prosthesis.
The PT that gave me the information about the powerchair eval is
wanting this education with her entire staff so that the pt can best
be served, not that she knows they cannot have both items from
Medicare.

Sorry this was so long. Hope it helps everyone.

Rachel Hartsell, CPO, LPO
Spears Prosthetics and Orthotics