Power Mobility Chair/AFO/ Medicare Guidelines Responses
Melissa Edwards
Description
Collection
Title:
Power Mobility Chair/AFO/ Medicare Guidelines Responses
Creator:
Melissa Edwards
Date:
10/13/2014
Text:
I received numerous responses of varying degrees. I have compiled them for anyone interested.
Explain & request from your physician to write two separate Rx's.
Each Rx has different uses. One Rx for mobility, and one is for limb contracture management. To prevent future contracture from arising.
Contracted limbs can also cause pain due to tone issues being exaggerated is they exist. Foot deformities having angulations from neutral can cause medial or lateral foot bruises leading to ulcers.
The list goes on, and on. Deformed feet cannot accept footwear that would protect the thin tissue over the dorsum of the feet or bony areas.
Does this help? You can't over document. Use before and after pictures if your allowed; some insurance companies may not permit them on a first billing.
Document, document, document. Be careful and ABN. We have an appeal with Medicare right now for a very active, young grandmother who is an A/K( patient looks after her two young grandchildren during the day). Medicare is requesting the usual Physician documentation for MPK. In DME MACs last letter they hinted with this comment Our records also note the beneficiary has been using a wheelchair since (date of amputation) and continues to use as evidenced by ongoing billing and payment for this chair making the K3 ambulatory status questionable. The patient has never presented to us or to Physical Therapy with a wheelchair of any kind. The patient presented in a wheeled walker and progressed to a Quad cane, then to a cane and finally to no assistive device. Of course, she would still have a wheelchair and would on a regular bases, need the use of, i.e., bathroom use at night, if for any reason her prosthetic would be cumbersome in a public place (air travel for instance) or convalescence for any number of medical reasons, major repair or simply by patient's choice.
That wheelchair will be a discussion topic at our hearing , but shouldn't be as it is only common sense to retain your wheelchair for the above mentioned reasons.
I think you will be OK. I just listened to a CGS webinar that explained a similar case of prosthesis & power chair. Basically, the speaker said there was an old CMS guideline that said you can not have a power chair & a prosthesis. She said that rule was changed (I think in 2012). She said there remains a similar issue, though. That is that an O&P device requires the patient to be ambulatory & a power chair requires the patient to be non-ambulatory.
Per your statement that the physician noted Has spastic paraparesis and weakness in walking, I would think you have the advantage because the doctor documented walking, although with weakness. Isn't an AFO most often indicated for weakness in ambulation of some sort?
Explain the issue to your patient and have them sign an ABN; with the understanding they may be responsible due to physician documentation.
You should be fine. An AFO is only covered if the patient is ambulatory. The physician's records showing he wants to patient to be more active/ambulatory will actually help prove the patient can ambulate. The power wheelchair actually won't interfere with you providing the AFO. Medicare Region C has not started denying Prosthetics or Orthotics if the patient has a power wheelchair.
Medicare's rules are below.
<URL Redacted>
AFOs AND KAFOs USED DURING AMBULATION:
Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:
1.Require stabilization for medical reasons, and,
2.Have the potential to benefit functionally.
Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.
If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and necessary.
AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria listed above and one of the following criteria are met:
1.The beneficiary could not be fit with a prefabricated AFO; or,
2.The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,
3.There is a need to control the knee, ankle or foot in more than one plane; or,
4.The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
5.The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.
If Medicare pays for the Power Wheelchair, they will most likely deny payment for the AFO based on the patient being non-ambulatory. We had an instance with a patient in which the patient walks into our office, we never see him with a wheelchair. We provided him a knee brace and Medicare denied it as not medically necessary due to the patient having a power wheelchair and therefore being non-ambulatory. I appealed it all the way to the Medicare Appeals Council and the claim was denied all the way through the appeal process.
Thank you for your post to OANDP-L!... We have had a very similar situation where we provided an individual with MS Bilateral KAFO's that included aceptional documentation and were denied following a Pre Payment Audit after we had provided the services and it has been in the appeal process for nearly 2 years now!!
The individual, their caregiver, spouse and referring physician wrote heartfelt letters seeking a reversal of the denial that would have brought any sane and reasonable person to their knees in shame and their pleas meant absolutely nothing to the appeals audit reviewer!!!
I would be curious to know and would be appreciative of knowing how many other's have had an individual struggling to maintain and improve their dignity and mobility that have been denied coverage as a result of a Medicare Audit for Orthotic services involving an individual diagnosed with MS?
It has been my long-standing experience that individuals diagnosed with MS often have and require a powered mobility device for use as they deal with the ebbs and flows in their strength and weaknesses during the course of a day, week or month to maintain their independence and mobility!
In our situation the KAFO's were determined to be Not Medically Necessary despite severe knee hyperextension deformities and advancing plantar flexion contractures. There was no mention of the individual having a powered mobility device, as being the reason for the denial.
Your situation is not an automatic disqualifier, but the physician documentation will have to be very detailed. I would say this will be a major red flag, and almost certain to attract a complex medical review, if not more. You may want to check and see if you are in one of the prior authorization test areas for these chairs. I have had both covered in similar situations, and they survived complex medical reviews, although none were done in the current documentation environment.
From a documentation standpoint, you have a real challenge, because you have to document multiple things as necessary. You mention new AFOs, which means that the necessity for replacements will have to be documented, and in this case, how the new AFOs will manage a necessity that neither the powered chair nor her existing AFOs cannot. In addition the chair will also have to be documented the same way, in that which necessary things the chair will permit that cannot be met without it, including the AFOs. It is not hard to envision functionally. If the current AFOs are intended for NWB use, a design change may be necessary, but I doubt that wants to be more active by itself will survive any review.
To propose one possible approach, if applicable: There may be general health benefits to being more active, which would require not only AFOs but different AFOs (define and explain), but also a critical endurance limit that cannot be met by ambulation alone (ADLs, for instance), thus the necessity of the powered chair. In addition, it will have to be documented why other mobility aids, such as a manual chair, cannot meet these needs. And you will have to be careful, because if you say, for instance, that her arm strength will not permit the use of a manual chair, it would be unlikely that someone with those limitations will be significantly ambulatory, as some kind of UE assistive device will almost certainly be necessary. And if the ADL requirements can be met by the powered chair, the necessity for the AFOs becomes sketchy, unless, again, there are other tangible benefits that her physician can elucidate.
Some things to think about from a physician documentation standpoint can be found here:
<URL Redacted>
And if you go to CMS.gov and search for powered mobility chair you can find other resources as well. Without knowing more about the patient, I couldn't say what your chances are, but no obvious reason to definitely say no, either.
Melissa Edwards
Insurance & Compliance Coordinator
[cid: <Email Address Redacted> ]
4338 Williamson Rd. NW
Roanoke, VA 24012
P:(540) 366-8287
F: (540) 767-0010
<Email Address Redacted>
Explain & request from your physician to write two separate Rx's.
Each Rx has different uses. One Rx for mobility, and one is for limb contracture management. To prevent future contracture from arising.
Contracted limbs can also cause pain due to tone issues being exaggerated is they exist. Foot deformities having angulations from neutral can cause medial or lateral foot bruises leading to ulcers.
The list goes on, and on. Deformed feet cannot accept footwear that would protect the thin tissue over the dorsum of the feet or bony areas.
Does this help? You can't over document. Use before and after pictures if your allowed; some insurance companies may not permit them on a first billing.
Document, document, document. Be careful and ABN. We have an appeal with Medicare right now for a very active, young grandmother who is an A/K( patient looks after her two young grandchildren during the day). Medicare is requesting the usual Physician documentation for MPK. In DME MACs last letter they hinted with this comment Our records also note the beneficiary has been using a wheelchair since (date of amputation) and continues to use as evidenced by ongoing billing and payment for this chair making the K3 ambulatory status questionable. The patient has never presented to us or to Physical Therapy with a wheelchair of any kind. The patient presented in a wheeled walker and progressed to a Quad cane, then to a cane and finally to no assistive device. Of course, she would still have a wheelchair and would on a regular bases, need the use of, i.e., bathroom use at night, if for any reason her prosthetic would be cumbersome in a public place (air travel for instance) or convalescence for any number of medical reasons, major repair or simply by patient's choice.
That wheelchair will be a discussion topic at our hearing , but shouldn't be as it is only common sense to retain your wheelchair for the above mentioned reasons.
I think you will be OK. I just listened to a CGS webinar that explained a similar case of prosthesis & power chair. Basically, the speaker said there was an old CMS guideline that said you can not have a power chair & a prosthesis. She said that rule was changed (I think in 2012). She said there remains a similar issue, though. That is that an O&P device requires the patient to be ambulatory & a power chair requires the patient to be non-ambulatory.
Per your statement that the physician noted Has spastic paraparesis and weakness in walking, I would think you have the advantage because the doctor documented walking, although with weakness. Isn't an AFO most often indicated for weakness in ambulation of some sort?
Explain the issue to your patient and have them sign an ABN; with the understanding they may be responsible due to physician documentation.
You should be fine. An AFO is only covered if the patient is ambulatory. The physician's records showing he wants to patient to be more active/ambulatory will actually help prove the patient can ambulate. The power wheelchair actually won't interfere with you providing the AFO. Medicare Region C has not started denying Prosthetics or Orthotics if the patient has a power wheelchair.
Medicare's rules are below.
<URL Redacted>
AFOs AND KAFOs USED DURING AMBULATION:
Ankle-foot orthoses (AFO) described by codes L1900, L1902-L1990, L2106-L2116, L4350, L4360, L4386, L4387 and L4631 are covered for ambulatory beneficiaries with weakness or deformity of the foot and ankle, who:
1.Require stabilization for medical reasons, and,
2.Have the potential to benefit functionally.
Knee-ankle-foot orthoses (KAFO) described by codes L2000-L2038, L2126-L2136, and L4370 are covered for ambulatory beneficiaries for whom an ankle-foot orthosis is covered and for whom additional knee stability is required.
If the basic coverage criteria for an AFO or KAFO are not met, the orthosis will be denied as not reasonable and necessary.
AFOs and KAFOs that are custom-fabricated are covered for ambulatory beneficiaries when the basic coverage criteria listed above and one of the following criteria are met:
1.The beneficiary could not be fit with a prefabricated AFO; or,
2.The condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or,
3.There is a need to control the knee, ankle or foot in more than one plane; or,
4.The beneficiary has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or,
5.The beneficiary has a healing fracture which lacks normal anatomical integrity or anthropometric proportions.
If Medicare pays for the Power Wheelchair, they will most likely deny payment for the AFO based on the patient being non-ambulatory. We had an instance with a patient in which the patient walks into our office, we never see him with a wheelchair. We provided him a knee brace and Medicare denied it as not medically necessary due to the patient having a power wheelchair and therefore being non-ambulatory. I appealed it all the way to the Medicare Appeals Council and the claim was denied all the way through the appeal process.
Thank you for your post to OANDP-L!... We have had a very similar situation where we provided an individual with MS Bilateral KAFO's that included aceptional documentation and were denied following a Pre Payment Audit after we had provided the services and it has been in the appeal process for nearly 2 years now!!
The individual, their caregiver, spouse and referring physician wrote heartfelt letters seeking a reversal of the denial that would have brought any sane and reasonable person to their knees in shame and their pleas meant absolutely nothing to the appeals audit reviewer!!!
I would be curious to know and would be appreciative of knowing how many other's have had an individual struggling to maintain and improve their dignity and mobility that have been denied coverage as a result of a Medicare Audit for Orthotic services involving an individual diagnosed with MS?
It has been my long-standing experience that individuals diagnosed with MS often have and require a powered mobility device for use as they deal with the ebbs and flows in their strength and weaknesses during the course of a day, week or month to maintain their independence and mobility!
In our situation the KAFO's were determined to be Not Medically Necessary despite severe knee hyperextension deformities and advancing plantar flexion contractures. There was no mention of the individual having a powered mobility device, as being the reason for the denial.
Your situation is not an automatic disqualifier, but the physician documentation will have to be very detailed. I would say this will be a major red flag, and almost certain to attract a complex medical review, if not more. You may want to check and see if you are in one of the prior authorization test areas for these chairs. I have had both covered in similar situations, and they survived complex medical reviews, although none were done in the current documentation environment.
From a documentation standpoint, you have a real challenge, because you have to document multiple things as necessary. You mention new AFOs, which means that the necessity for replacements will have to be documented, and in this case, how the new AFOs will manage a necessity that neither the powered chair nor her existing AFOs cannot. In addition the chair will also have to be documented the same way, in that which necessary things the chair will permit that cannot be met without it, including the AFOs. It is not hard to envision functionally. If the current AFOs are intended for NWB use, a design change may be necessary, but I doubt that wants to be more active by itself will survive any review.
To propose one possible approach, if applicable: There may be general health benefits to being more active, which would require not only AFOs but different AFOs (define and explain), but also a critical endurance limit that cannot be met by ambulation alone (ADLs, for instance), thus the necessity of the powered chair. In addition, it will have to be documented why other mobility aids, such as a manual chair, cannot meet these needs. And you will have to be careful, because if you say, for instance, that her arm strength will not permit the use of a manual chair, it would be unlikely that someone with those limitations will be significantly ambulatory, as some kind of UE assistive device will almost certainly be necessary. And if the ADL requirements can be met by the powered chair, the necessity for the AFOs becomes sketchy, unless, again, there are other tangible benefits that her physician can elucidate.
Some things to think about from a physician documentation standpoint can be found here:
<URL Redacted>
And if you go to CMS.gov and search for powered mobility chair you can find other resources as well. Without knowing more about the patient, I couldn't say what your chances are, but no obvious reason to definitely say no, either.
Melissa Edwards
Insurance & Compliance Coordinator
[cid: <Email Address Redacted> ]
4338 Williamson Rd. NW
Roanoke, VA 24012
P:(540) 366-8287
F: (540) 767-0010
<Email Address Redacted>
Citation
Melissa Edwards, “Power Mobility Chair/AFO/ Medicare Guidelines Responses,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/236830.
