Documentation for Lower Limb Prosthesis

by  Medicare Learning Network
March 8th, 2018

The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:

Reasons for Denial – Insufficient Documentation

For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.

For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s medical condition(s) that requires the use of the specifically ordered lower limb prosthetic as well as beneficiary’s medical condition(s) that would impact the beneficiary’s ability to effectively utilize the specifically ordered lower limb prosthetic in achieving a defined functional state. The medical record is not limited to physician’s office records but may include:

The Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) received a high volume of submitted claims for lower limb prosthetic covers and protective covering systems for the same lower limb prosthesis. The need for both of these is rare. (For details refer to http://www.aopanet.org/codingreimbursement/coding-issues .)

To Prevent Denials

A medical necessity determination for certain components/additions to the prosthesis is based on the beneficiary’s potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:

Base clinical assessments of beneficiary rehabilitation potential on the following classification levels:

The records must contain documentation on the beneficiary’s current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. It is recognized, within the functional classification hierarchy, that bilateral amputees often cannot be strictly bound by functional level classifications.

References:

Documentation for Lower Limb Prosthesis. (2018, March 8). Find-A-Code Articles. Retrieved from https://www.findacode.com/articles/d-33372.html

© InnoviHealth Systems Inc

Article Tags  (click on a tag to see related articles)


Publish this Article on your Website, Blog or Newsletter

This article is available for publishing on websites, blogs, and newsletters. The article must be published in its entirety - all links must be active. If you would like to publish this article, please contact us and let us know where you will be publishing it. The easiest way to get the text of the article is to highlight and copy. Or use your browser's "View Source" option to capture the HTML formatted code.

If you would like a specific article written on a medical coding and billing topic, please Contact Us.


contact

innoviHealth Systems, Inc.
62 East 300 North
Spanish Fork, UT 84660
Phone: 801-770-4203 (9-5 Mountain)
Email:
free demo
request yours today
pricing
for any budget
sign IN
welcome back!

Thank you for choosing Find-A-Code, please Sign In to remove ads.