C leg RAC Audit and new symes on other side
Karl Entenmann
Description
Collection
Title:
C leg RAC Audit and new symes on other side
Creator:
Karl Entenmann
Date:
7/18/2013
Text:
Hi all,
We have recently inherited a patient from another facility that has closed its doors due to RAC audits. The patient is a 59 year old man who was fitted with a C leg on his AK side about 2 years ago and has done fairly well with it. Medicare has done a RAC audit on that C leg and it is somewhere in the bowels of appeals. We have inherited this gentleman who now has a new Symes amputation on the other side. The C leg was surely billed with a K3 and we cannot justify a K3 for him at this time. He may well have been a K3 when fitted with the C leg but we have not been able to observe that because we did not know him prior to the Symes amputation and he is just now ready to be fitted.
So here are the questions: The C leg had a Trias foot and our first thoughts of course were to try to match the Symes foot with a similar functional level foot as he is used to on the C leg. However, we are almost smart enough not to go down that slippery slope. We'll probably start him off on a K2 foot and make him prove he can function at a K3 before any thoughts of upgrading. We are working with the physician to make sure very detailed and proper current documentation is in the clinical record for both the Symes and the C leg, but we have no control over past documentation.
The second issue is that the C leg socket is now too large and really needs to be replaced. But, if Medicare denies the C leg as not medically necessary due to documentation, we will not get paid for a socket replacement on a prosthesis that doesn't exist in Medicare's eyes. Nice delema.
So, any suggestions? ABN, of course, but is the patient really going to be able to pay for a socket replacement? How about the foot issue? Does a bilateral patient fall under the functional levels of Medicare? Medicare states in the current LCD that it is recognized, within the functional classification hierarchy, that
bilateral amputees often cannot be strictly bound by functional level
classifications. Does this mean that with proper documentation, a bilateral amputee can be fit with the higher level foot?
I do not want to lose an audit on this. I expect it to be audited. Thanks for your input.
Sincerely,
Karl W. Entenmann, CPO
Still open at Preferred O and P
Federal Way, WA
We have recently inherited a patient from another facility that has closed its doors due to RAC audits. The patient is a 59 year old man who was fitted with a C leg on his AK side about 2 years ago and has done fairly well with it. Medicare has done a RAC audit on that C leg and it is somewhere in the bowels of appeals. We have inherited this gentleman who now has a new Symes amputation on the other side. The C leg was surely billed with a K3 and we cannot justify a K3 for him at this time. He may well have been a K3 when fitted with the C leg but we have not been able to observe that because we did not know him prior to the Symes amputation and he is just now ready to be fitted.
So here are the questions: The C leg had a Trias foot and our first thoughts of course were to try to match the Symes foot with a similar functional level foot as he is used to on the C leg. However, we are almost smart enough not to go down that slippery slope. We'll probably start him off on a K2 foot and make him prove he can function at a K3 before any thoughts of upgrading. We are working with the physician to make sure very detailed and proper current documentation is in the clinical record for both the Symes and the C leg, but we have no control over past documentation.
The second issue is that the C leg socket is now too large and really needs to be replaced. But, if Medicare denies the C leg as not medically necessary due to documentation, we will not get paid for a socket replacement on a prosthesis that doesn't exist in Medicare's eyes. Nice delema.
So, any suggestions? ABN, of course, but is the patient really going to be able to pay for a socket replacement? How about the foot issue? Does a bilateral patient fall under the functional levels of Medicare? Medicare states in the current LCD that it is recognized, within the functional classification hierarchy, that
bilateral amputees often cannot be strictly bound by functional level
classifications. Does this mean that with proper documentation, a bilateral amputee can be fit with the higher level foot?
I do not want to lose an audit on this. I expect it to be audited. Thanks for your input.
Sincerely,
Karl W. Entenmann, CPO
Still open at Preferred O and P
Federal Way, WA
Citation
Karl Entenmann, “C leg RAC Audit and new symes on other side,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/235334.
