response on trilateral in power chair
tennesselimbandbrace
Description
Collection
Title:
response on trilateral in power chair
Creator:
tennesselimbandbrace
Date:
7/3/2013
Text:
Here is my original post thanks for all the responses..
hello all, I have a tri-amputee AKA/BKA and partial hand that is requesting through his physician to have prosthesis made. He is a new amputee post op 4 weeks and should be ready for casting in a couple of weeks. My question is he also is in the process of getting a power chair and what requirements or restriction does Medicare place on this type of amputee? Any information is greatly appreciated.
Barry Davidson CP
Tn limb and brace
My understanding, at least in our jurisdiction, is that Medicare WILL NOT pay for a prosthesis or orthosis if the patient has a power mobility device. If the patient gets a power mobility device Medicare considers this to be the patient's way of getting around and that they are not ambulatory. I have spoke to two different Medicare representatives about my orthotic patients with power wheelchairs and was strongly encouraged to get an ABN to put the responsibility on the patient in the event Medicare doesn't pay (which is not likely). We also have a patient, a K3 BK amputee, who got a power wheelchair from a friend that he uses like a car (he drives the chair to appointments and around town instead of a car). He submitted repair costs to Medicare even though Medicare never paid for the chair nor was there any physician documentation on file for the chair. We are being denied his replacement socket as Medicare now knows he has a power chair and therefore believes he doesn't need his prosthesis. My recommendation is to proceed carefully, get ABN's signed and even call the Medicare representatives to discuss
I believe if Medicare provides and pays for a power chair they will not pay for his prosthetics too. They feel if he needs a power chair to get around he will not be using prosthetics.
I would start with the hand first. this should not be affected by the power chair since obviously nothing to do with mobility plus it would help walking in the parallel bars once the leg prostheses are made. I believe I would start with classifying him as functional level 2 and then proceed from there. you may end up in front of the ALJ over this one so the other train of thought is classify at level 3 because you will end up there anyway. CMS states that bilaterals cannot be bound by functional levels but they don't say how necessarily to address it. some of the approach could obviously be based on what he did prior to the surgery and any other co-morbidities. If he was very active prior and has no other co-morbidities then you would have a strong argument for level 3 if that is what you want. long-term wear on the knee on the transtibial side just from using it close to 100% for going from sit to stand and stand to sit could help justify a hydraulic knee on the transfemoral which means he would have to be K3. based on the little information given this reply is based on a lot of assumptions. anticipate that since the audits will use any possible excuse to reclaim that money, any mix of power chair and prosthetics is going to be a red flag. In cases like this you have to really consider the best interest of the patient and hopefully you can take care of him with minimal interference and problems. good luck.
I've been told that, in order for Medicare to pay for the power chair, documentation must support the fact that the patient is not capable of functional ambulation. To get paid on a leg, of course, documentation must support the fact that the patient is capable of ambulating AND is highly motivated to ambulate.
Zita Upchurch, from CMS, has expressly stated that power chair=no coverage for prostheses.
If a patient is getting a power chair, chances are someone has signed documentation that the patient can't walk and, therefore, does not need a prosthesis. Patients are almost never informed that getting a power chair means they can never receive a prosthesis.
We have provided legs to patients with power chairs, with good documentation, but it is a risk. 5 years from delivery, medicare can take their money back. We are at a disadvantage in that we work off the premise that if we are doing the right thing for the patient, we will get paid for our work. RAC audits have shown that this is not the case. Power chair companies are businesses. They abuse the system but know how to get paid and keep their money.
Barry,
This question was addressed at the Medicare Forum in NH last year. The CMS
Medical Director stated that Medicare's primary requirement for the power
wheelchair is that the patient is not ambulatory. If a doctor states the
patient is not ambulatory, you will not be able to get paid for a lower limb
prosthesis.
When I recently inquired looking for something in writing on this topic, as
we have a patient that got a power wheelchair some years ago, this is the
response I received:
hello all, I have a tri-amputee AKA/BKA and partial hand that is requesting through his physician to have prosthesis made. He is a new amputee post op 4 weeks and should be ready for casting in a couple of weeks. My question is he also is in the process of getting a power chair and what requirements or restriction does Medicare place on this type of amputee? Any information is greatly appreciated.
Barry Davidson CP
Tn limb and brace
My understanding, at least in our jurisdiction, is that Medicare WILL NOT pay for a prosthesis or orthosis if the patient has a power mobility device. If the patient gets a power mobility device Medicare considers this to be the patient's way of getting around and that they are not ambulatory. I have spoke to two different Medicare representatives about my orthotic patients with power wheelchairs and was strongly encouraged to get an ABN to put the responsibility on the patient in the event Medicare doesn't pay (which is not likely). We also have a patient, a K3 BK amputee, who got a power wheelchair from a friend that he uses like a car (he drives the chair to appointments and around town instead of a car). He submitted repair costs to Medicare even though Medicare never paid for the chair nor was there any physician documentation on file for the chair. We are being denied his replacement socket as Medicare now knows he has a power chair and therefore believes he doesn't need his prosthesis. My recommendation is to proceed carefully, get ABN's signed and even call the Medicare representatives to discuss
I believe if Medicare provides and pays for a power chair they will not pay for his prosthetics too. They feel if he needs a power chair to get around he will not be using prosthetics.
I would start with the hand first. this should not be affected by the power chair since obviously nothing to do with mobility plus it would help walking in the parallel bars once the leg prostheses are made. I believe I would start with classifying him as functional level 2 and then proceed from there. you may end up in front of the ALJ over this one so the other train of thought is classify at level 3 because you will end up there anyway. CMS states that bilaterals cannot be bound by functional levels but they don't say how necessarily to address it. some of the approach could obviously be based on what he did prior to the surgery and any other co-morbidities. If he was very active prior and has no other co-morbidities then you would have a strong argument for level 3 if that is what you want. long-term wear on the knee on the transtibial side just from using it close to 100% for going from sit to stand and stand to sit could help justify a hydraulic knee on the transfemoral which means he would have to be K3. based on the little information given this reply is based on a lot of assumptions. anticipate that since the audits will use any possible excuse to reclaim that money, any mix of power chair and prosthetics is going to be a red flag. In cases like this you have to really consider the best interest of the patient and hopefully you can take care of him with minimal interference and problems. good luck.
I've been told that, in order for Medicare to pay for the power chair, documentation must support the fact that the patient is not capable of functional ambulation. To get paid on a leg, of course, documentation must support the fact that the patient is capable of ambulating AND is highly motivated to ambulate.
Zita Upchurch, from CMS, has expressly stated that power chair=no coverage for prostheses.
If a patient is getting a power chair, chances are someone has signed documentation that the patient can't walk and, therefore, does not need a prosthesis. Patients are almost never informed that getting a power chair means they can never receive a prosthesis.
We have provided legs to patients with power chairs, with good documentation, but it is a risk. 5 years from delivery, medicare can take their money back. We are at a disadvantage in that we work off the premise that if we are doing the right thing for the patient, we will get paid for our work. RAC audits have shown that this is not the case. Power chair companies are businesses. They abuse the system but know how to get paid and keep their money.
Barry,
This question was addressed at the Medicare Forum in NH last year. The CMS
Medical Director stated that Medicare's primary requirement for the power
wheelchair is that the patient is not ambulatory. If a doctor states the
patient is not ambulatory, you will not be able to get paid for a lower limb
prosthesis.
When I recently inquired looking for something in writing on this topic, as
we have a patient that got a power wheelchair some years ago, this is the
response I received:
Citation
tennesselimbandbrace, “response on trilateral in power chair,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 1, 2024, https://library.drfop.org/items/show/235417.
