Powerscooter & Lower Limb Prosthesis
Mark Maguire
Description
Collection
Title:
Powerscooter & Lower Limb Prosthesis
Creator:
Mark Maguire
Date:
8/5/2013
Text:
Good morning everyone, I was able reach someone within one of the DMEMAC's who was willing to address the power scooter/wheelchair issue regarding lower limb prosthetics and I received the below email in response. If you understand what the below email is telling you it might be possible to explain to a prescribing physician what conditions need to be met when prescribing a prosthesis for a patient who has previously been provided a power wheelchair/scooter. I will tell you that I currently have a patient who not only has a power scooter/wheelchair but is also wearing a K3 prosthesis provided by a competitor, and based on his history and what I understand below, I believe I can safely proceed with providing this gentleman with a K2 replacement prosthesis. I will let his physician make the final determination on the prosthesis and K-level because based on what I generally understand; which is not supported by the below email, I do not believe a Prosthetist should make the determination of a patient's K-level. I hope this helps.
Good Morning Mark,
I did discuss your question with our Medical Director. What I want to mention first is that repairs and replacements are controlled (guided) by the requirements set out in the Benefit Policy Manual Sections 110 (for general requirements) and 120 (for requirements specific to artificial legs, arms and eyes).
Section 110 says that an item , owned by the beneficiary is eligible for repairs to be covered. It does place some limits on full replacement (meaning getting an entire new item) and also excludes full replacement due to wear and tear.
Section 120 says that artificial arm, legs and eyes can be replaced upon the order of a physician . The section specifically says,
Finally, the Benefits Improvement and Protection Act of 2000 amended §1834(h)(1) of the Act by adding a provision (1834 (h)(1)(G)(i)) that requires Medicare payment to be made for the replacement of prosthetic devices which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if an ordering physician determines that the replacement device, or replacement part of such a device, is necessary.
Payment may be made for the replacement of a prosthetic device that is an artificial limb, or replacement part of a device if the ordering physician determines that the replacement device or part is necessary because of any of the following:
1. A change in the physiological condition of the patient;
2. An irreparable change in the condition of the device, or in a part of the device; or
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.
This provision is effective for items replaced on or after April 1, 2001. It supersedes any rule that that provided a 5-year or other replacement rule with regard to prosthetic devices
As for what should be documented. The policy says that the prosthetist gets to specify the K-level. Thus their records have to clearly explain and justify that choice. What the policy says is that the level of activity specified has to correspond to or be consistent with the beneficiaries overall health status. Only a physician can discuss the patients overall health. So for example, if a prosthetist selected a K3 we would expect to see the general health reflected in the overall record to be pretty good since as a K3 community ambulatory, the expectation is for an active life. Someone with a bad heart or lung would not likely be able to engage at the level of activity expected for K3 even though the beneficiary might be capable of using components designated for that level.
In this scenario, I would recommend that there be a complete discussion in the prosthetic record about the change in activity and condition that justify the change in level. That discussion needs to be supported by medical information that describes a health status that is consistent with the prosthetic assessment.
Mark T. Maguire, CPO
Good Morning Mark,
I did discuss your question with our Medical Director. What I want to mention first is that repairs and replacements are controlled (guided) by the requirements set out in the Benefit Policy Manual Sections 110 (for general requirements) and 120 (for requirements specific to artificial legs, arms and eyes).
Section 110 says that an item , owned by the beneficiary is eligible for repairs to be covered. It does place some limits on full replacement (meaning getting an entire new item) and also excludes full replacement due to wear and tear.
Section 120 says that artificial arm, legs and eyes can be replaced upon the order of a physician . The section specifically says,
Finally, the Benefits Improvement and Protection Act of 2000 amended §1834(h)(1) of the Act by adding a provision (1834 (h)(1)(G)(i)) that requires Medicare payment to be made for the replacement of prosthetic devices which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if an ordering physician determines that the replacement device, or replacement part of such a device, is necessary.
Payment may be made for the replacement of a prosthetic device that is an artificial limb, or replacement part of a device if the ordering physician determines that the replacement device or part is necessary because of any of the following:
1. A change in the physiological condition of the patient;
2. An irreparable change in the condition of the device, or in a part of the device; or
3. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced.
This provision is effective for items replaced on or after April 1, 2001. It supersedes any rule that that provided a 5-year or other replacement rule with regard to prosthetic devices
As for what should be documented. The policy says that the prosthetist gets to specify the K-level. Thus their records have to clearly explain and justify that choice. What the policy says is that the level of activity specified has to correspond to or be consistent with the beneficiaries overall health status. Only a physician can discuss the patients overall health. So for example, if a prosthetist selected a K3 we would expect to see the general health reflected in the overall record to be pretty good since as a K3 community ambulatory, the expectation is for an active life. Someone with a bad heart or lung would not likely be able to engage at the level of activity expected for K3 even though the beneficiary might be capable of using components designated for that level.
In this scenario, I would recommend that there be a complete discussion in the prosthetic record about the change in activity and condition that justify the change in level. That discussion needs to be supported by medical information that describes a health status that is consistent with the prosthetic assessment.
Mark T. Maguire, CPO
Citation
Mark Maguire, “Powerscooter & Lower Limb Prosthesis,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 24, 2024, https://library.drfop.org/items/show/235519.
