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Power Mobility Devices and Prosthetic limbs
Posted By: Jim DeWees on September 6, 2016
Hello Everyone, I have a question regarding Medicare benefits and coverage when a patient has recently received a Power Mobility Device (Scooter, electric wheelchair, etc.) and now are wanting to also have a prosthetic leg. Do you provide services to these patients? Do you get paid? Have you been audited on these claims? The reason I am asking is because I currently have a patient who recently received a scooter AND is now in the process of getting a prosthetic leg (above the knee). She originally started the process at another facility which is much closer to her home. For some reason (unknown) she quit going to them and came to my office to get this leg. I always ask the patient about if they have gotten any kind of power mobility device, AND I also check the website/portal/connex, etc. to see if Medicare (or private insurance) has paid for any of these items recently. BUT since Region B is now with CGI, I still have not gotten my password and username to get onto their system/website to check on this patient. (That is ANOTHER story that I should share here...maybe another day..) In her chart notes from the doctor, it states clearly that this patient is afraid to use her new scooter because it is top heavy and she is afraid that she will fall over with it and get injured. The Physical Therapist also documented something about her new scooter. When I asked the patient again about if she has a scooter, she said "NO" and then I showed her the doctor's notes, and she looked puzzled and said she had no idea why the doctor would write something like that. THEN her daughter gave her the evil eye, like "tell the truth" kind of look at her mother, and then she said that she DID have a scooter, but it is NOT an "electric wheelchair" and then she also said her husband paid cash for this. I called the doctor's office and finally was able to find out WHO provided this scooter (where they sent the referral and chart notes). I called this company to ask them, and only found out that this company is closed and out of business. (I actually ended up calling the stores that were near this office to ask if they were still at this address, both of the businesses I talked to told me that the company closed and quit, and is no longer at this location.) The phone numbers of this company say that they are no longer in service, to check the number and try again.... I cannot get online to check if this is true or not. I SHOULD be online with CGI sometime in the next week or so. This should have been set up MONTHS ago, Also, about 3 years ago, I had another patient who was a high K-3 level amputee who enjoyed going mushroom hunting (hiking trails in the hills and woods in southern Indiana), he also was a mechanic and did heavy lifting and other jobs like that. I had NO reason to even THINK that he would have an electric wheelchair. I made him a new leg, a physical therapist did the mobility predictor for him, he had a high K-3 score. The physician also noted that this man was a strong and healthy male who did heavy lifting for his work, etc. BUT some doctor a few months prior to this said that this man had no potential to ambulate, his upper body strength was horrible, he could not propel a manual wheelchair due to his overall weakness in his body, etc. He qualified for a "power mobility device" and Medicare paid for a nice scooter for him from one of these stores who advertised on TV to get a scooter "At little or no cost to you".... He uses this scooter in places like Walmart, Flea Markets, the Theme Park nearby, county fairs, etc. (I know this is NOT the intended use for a power mobility device as Medicare states in their policies....it is for in-home use only). Anyway, I had a pre-payment audit on this claim, and it was denied because he had recently gotten this PMD. It was determined to NOT be medically necessary for him to have a prosthetic leg. They stated that this man had no ability or potential to walk according to the documentation received by Medicare with the paperwork for him to get this power wheelchair. So, they stated there is no way that this man could be a K-3 level amputee and the ability to perform at K-3 levels. I stated that a physical therapist, who is in no way connected to my business, who has NO vested interest in my company, is the one who determined this score. This patient does all kinds of activities where he NEEDS a prosthetic leg so he can walk, work, and do all of the things that he does. Medicare (NGS) did not budge on this issue and stated that they will not cover the prosthetic leg since he had recently gotten this PMD. I do not know if they went after the company that provided the wheelchair/scooter to him and got their money back from them. I can totally understand when Medicare gets this kind of information saying the patient cannot even stand or walk at all, and then at the same time another set of documentation stating that he walks with NO limitations at all. WHO do they believe??? How can they trust either of us??? So I have basically made it my policy to NOT provide any prosthetic services to patients who have recently gotten any kind of power mobility devices. I am wanting to know from others what they are doing in these situations. How do you get paid for any prosthetic leg for a patient when the documentation for the PMD states the patient has no ability to walk at all, but to be even at a K-1 level amputee, they need be able to at least walk on level surfaces at a fixed cadence, etc. The bottom line is this: do you provide services for patients who have recently received any power mobility device through Medicare? Have you gotten paid? Have you been audited on these claims? Have you had to pay money back in a RAC audit for any of these situations? I am now working with CGI for Region B Medicare. NGS is no longer in the picture here. What has CGI (Region C) done in these situations? Does anyone have any experience with CGI regarding PMD and Prosthetic legs? Thanks Jim DeWees, CP |
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