oandp.com

Dear Colleagues and Guests,

The CMS (Noridian) prosthetic checklist for lower limb prostheses for
"Region D" is now located at oandpsolutions.org as a link under NAS
(Noridian Administrative Services). One noteworthy item is under
functional levels, Noridian states that certain components/additions are
based on patient's potential functional abilities based on reasonable
expectations of the prosthetist and treating physician considering
factors including.....

This indicates that prosthetists do indeed participate in determining
the functional levels of amputees as related to prosthetic care. It also
indicates that only certain components are involved in functional
levels. As such, it would seem reasonable that if K3 were the only item
in question for a given amputee, then the foot and knee would be the
only items in dispute. It does not make sense that Medicare would deny
the entire claim when this is the case.

Other significant information in this document states that determination
of type of foot and/or knee is made by treating physician and/or
prosthetist based on functional needs of patient. In my opinion, this
indicates that the prosthetist does have the authority to determine
functional levels in the absence of same from the physician. However,
Noridian does state that sufficient clinical documentation of functional
need for the technologic or design feature of a given foot or knee is
required. This then makes the clinical records of prosthetists more
important inasmuch that the records of prosthetists can then be used for
valid clinical documentation. It would seem logical then that if a
prosthetist determines functional level and forwards this information to
the prescribing physician for agreement and insertion into their
records, this would suffice regarding Medicare regulations.

Noridian states that items included in reimbursement for prosthesis
include, evaluation of residual limb and gait, fitting of prosthesis,
cost of base components parts and labor contained in HCPCS base code,
repairs due to normal wear or tear within 90 days of delivery, and
adjustments of prosthesis or prosthetic components made when fitting
prosthesis or component and for 90 days from date of delivery when
adjustments are not necessitated by changes in residual limb or
patient's functional abilities. Since physicians and therapists are
required to obtain a DMEPOS billing number, why would they be exempt
from the regulations that are printed for the DMEPOS supplier? Has CMS
answered this question?

Any disagreement or comment?

Wil Haines, CPO
MaxCare Bionics
Avon, IN