oandp.com

*Dear List serve:*
*How many facilities are having problems with obtaining the clinical
information required by these Cert audits?*
*How many of your physicians are refusing to comply with these requirements?
*
*What are typical responses besides "I don't get paid enough to spend all
this time for you to get paid"?*
*Does it seem reasonable that in example 2 below that a replacement socket
would need this missing information if it was provided for the original
prosthesis?*
*Are there vascular surgeons in private practice that are willing to
provide a comprehensive evaluation for a prosthetic prescription?*
*Would it seem proper to have only physicians knowledgeable and willing to
complete a full evaluation to be the only ones able to prescribe a
prosthesis?*
*How many patients do you feel are being delayed or denied care because of
these requirements?*
*Thank you for your thoughts. *

*August 02, 2012*
*May*
*Lower Limb Prostheses - LCD L11464*
*L7368-K3-LT* - Lithium ion battery charger
*L5850-K3-LT* - Addition, endoskeletal system, above knee or hip
disarticulation, alignable system
*L8430-K3-LT* - Prosthetic sock, multiple ply, above knee, each
# of units billed =2
*L8480-K3-LT* - Prosthetic sock, single ply, fitting, above knee, each
# of units billed =2
*L5856-K3-LT* - Addition to lower extremity prosthesis, endoskeletal
knee-shin system, microprocessor control feature
*L5828-K3-LT* - Addition, endoskeletal knee-shin system, single axis, fluid
swing & stance phase control
*L5845-K3-LT* - Addition, endoskeletal, knee-shin system, stance flexion
feature, adjustable
*L5848-K3-LT* - Addition to endoskeletal knee-shin system, fluid stance
extension dampening feature, w/ or w/o adjustability
*L5950-K3-LT* - Addition, endoskeletal system, above knee, ultra-light
material (titanium, carbon fiber or equal)
*L5987-K3-LT* - All lower extremity prostheses, shank foot system w/
vertical loading pylon
*L5984-K3-LT* - All endoskeletal lower extremity prostheses, axial rotation
unit, w/ or w/o adjustability.
*L5673-K3-LT* - Addition to lower extremity, below knee/ above knee, custom
fabricated from existing mold or prefabricated, socket insert, silicone
gel, elastometric or equal, for use with locking mechanism.
# of units billed =
*L5671-K3-LT* - Addition to lower extremity, below knee/ above knee
suspension locking mechanism, excludes socket insert
Date of Service: 10/06/11

- Received - Proof of delivery; orders which are signed but not dated by
the physician; supplier documentation from the CPO; 2005 documentation
relating to amputation.
- *Missing - Order which has been signed and dated by the physician.
Also missing current clinical documentation, supporting medical management
of amputation status and level of ambulation.*


*L5701-LT-K3* - Replacement, socket, above knee/ knee disarticulation
*L5650-LT-K3* - Addition to lower extremity, total contact, above knee or
knee disarticulation socket
*L5624-LT-K3* - Addition to lower extremity, test socket, above knee
*L5631-LT-K3* - Addition to lower extremity, above knee or knee
disarticulation, acrylic socket
*L5651-LT-K3* - Addition to lower extremity, above knee, flexible inner
socket, external frame
*L5652-LT-K3* - Addition to lower extremity, suction suspension, above knee
or knee disarticulation socket
*L5695-LT-K3* - Addition to lower extremity, above knee, pelvic control,
sleeve suspension, neoprene or equal, each
Date of Service: 11/29/11

- Received - Physician order dated 10/25/11 for billed items; supplier
evaluation; visit notes dated 09/06/11 - 11/25/11; physician office visit
notes dated 12/21/10 - 03/16/12 that support medical management of
beneficiary's above the knee amputation, including beneficiary's current
condition, status of the residual limb, and the nature of other medical
problems.
- *Missing - Treating physician's clinical documentation that includes a
clinical assessment (using classification levels K0-K4) of beneficiary's
rehabilitation potential; documentation that supports beneficiary will
reach or maintain a K3 functional state within a reasonable period of time,
and is motivated to ambulate.*

*April*
*Lower Limb Prostheses - LCD L11464*
*L5700-LT-K3* - Replacement, socket, below knee, molded to patient model
*L5620-LT-K3* - Addition to lower extremity, test socket, below knee
# of units billed =
*L5629-LT-K3* - Addition to lower extremity, below knee, acrylic socket
*L5637-LT-K3* - Addition to lower extremity, below knee, total contact
*L5645-LT-K3* - Addition to lower extremity, below knee, flexible inner
socket, external frame
*L5910-LT-K3* - Addition, endoskeletal system, below knee, alignable system
*L5940-LT-K3* - Addition, endoskeletal system, below knee, ultra-light
material (titanium, carbon fiber or equal)
*L5671-LT-K3* - Addition to lower extremity, below knee/above knee
suspension locking mechanism, excludes socket insert
*L5673-LT-K3* - Addition to lower extremity, below knee/above knee, custom
fabricated from existing mold or prefabricated, socket insert, silicone
gel, elastometric or equal, for use with locking mechanism.
# of units billed =
Date of Service: 10/27/11

- Received - Illegible physician's documentation, including unsigned
History & Physical (H&P) dated 06/16/11 documenting amputation on 12/3/10;
illegible progress notes (dated ?/06/11, 08/18, 01/19/12); Order dated
09/16/11; Prosthetist's documentation ranging from 03/15/11- 10/25/11 with
delivery of replacement socket due to volume loss; Physical therapy
evaluation dated 02/01/11 and signed with illegible signature documenting
history of renal transplant on 03/10/09, status post left BKA on 12/13/10,
and debridement of stump/revision on 01/27/11; PT progress notes from
04/05/11- 04/16/11; PT evaluation dated 04/22/11 on admission to rehab
facility with new prosthesis; physical therapy progress note dated
04/29/11- 05/27/11 documenting ambulation 110 feet with RW and prosthesis;
home PT note for 05/27/11-06/10/11; forms labeled Activity Report.
- *Missing - Detailed physician order that includes each separately
billed component with quantity for each item; authenticated legible
clinical documentation, to include beneficiary's history, medical problems,
desire to ambulate, current condition, and potential functional status to
support Replacement Below Knee Socket and Additions for billed date of
service 10/27/11.*


*L5679-LT-K4* - Addition to lower extremity, below knee/above knee custom
fabricated from existing mold or prefabricated
*L8420-LT-K4* - Prosthetic sock, multiple ply, below knee, each
# of units billed =0
*L8470-LT-K4* - Prosthetic sock, single ply, fitting, below knee, each
# of units billed =0
*L8417-LT-K4* - Prosthetic sheath/sock, including a gel cushion layer,
below knee or above knee, each
# of units billed =
*L5986-LT-K4* - All lower extremity prostheses, multi-axial rotation unit
*L5987-LT-K4* - All lower extremity prostheses, shank foot system w/
vertical loading pylon
Date of Service: 10/27/11

- Received - Physician order dated 10/03/11; letter of medical necessity
dated 10/03/11; supplier progress notes dated 10/06/11 - 11/07/11; delivery
ticket; physician office visit notes dated 11/04/10 and 10/14/11; letter of
medical necessity dated 03/14/11.
- *Missing - Treating physician's clinical assessment (using
classification levels K0-K4) of beneficiary rehabilitation potential that
document beneficiary's past history, current condition including the status
of the residual limb, and nature of other medical problems; documentation
that supports prosthetist's functional level of K4, and is motivated to
ambulate.*