Documenting Replacement Prostheses
The #1 reason for claim denial for prosthetic claims is a lack of or insufficient physician documentation supporting the need for replacement.
Any claim involving the replacement of a major prosthesis (foot, ankle, knee, upper extremity socket) must have a signed physician's order and medical record documentation supporting the need for the replacement. The treating physician must detail the reason for replacement, such as:
- Significant changes in the patient's condition
- Changes in the residual limb
- Functional need changes
- The device is beyond repair
- Repairs exceed 60 % of the cost of the replacement
- The prosthesis is lost or stolen
What does this mean for you?
When your patient needs a new prosthesis or socket, make sure the patient has seen a treating physician recently. Ask the physician for detailed notes outlining the reason for replacement, the patient's functional level, and the continued need of the device. Create a new Detailed Written Order (DWO) for the physician to sign.
When billing the item, use the associated HCPCS codes with the LT or RT modifier, K level modifier, and the RA modifier. RA indicates this is a replacement device.
More information about replacements can be found in the Local Coverage Article: Lower Limb Prostheses – Policy Article (A52496)