Lower Limb Prostheses LCD

What You Need to Know:

The second part of the LCD is the Functional Levels section (usually referred to as “K Levels”). This is one of the most important parts of the LCD, as the patients’ functional level determines their access to certain types of prosthetic knees and feet. The Functional Levels section contains three elements: (1) how to assess a patient’s potential functional ability, (2) the functional level definitions, and (3) general functional level guidance. We’ll address each in turn:

• Potential: For prosthetists to determine the medical necessity of different components, they must base their analysis “on the beneficiary’s potential functional abilities.” [emphasis added] Prosthetists can determine potential functional ability by considering (a) their reasonable expectations of the patient, (b) the reasonable expectations of the treating practitioner (e.g., physician), (c) the beneficiary’s past history, (d) the beneficiary’s current condition, and (e) the beneficiary’s desire to ambulate, as well as any other relevant factors.
• Classification Levels:
• Level 0: The patient does not have the potential to ambulate or transfer safely, even with assistance. The prosthesis does not enhance their quality of life or mobility.
• Level 1:  The patient has the ability or potential to use a prosthesis to transfer or walk on level ground at a fixed speed. (Limited and unlimited household ambulator.)
• Level 2: The patient has the ability or potential to navigate curbs, stairs, or uneven surfaces (“low-level environmental barriers”). (Limited community ambulator.)
• Level 3: The patient has the ability or potential to walk at different speeds. Has the ability to traverse most environmental barriers. May have vocational, therapeutic, or exercise activity demanding prosthetic use beyond simple locomotion. (Unlimited community ambulator.)
• Level 4: The patient has ability or potential beyond basic walking, exhibiting high impact, stress, or energy levels. (Child, active adult, athlete.)
• General Guidance:
• The medical records – both the prosthetist’s and physician’s – must document the patient’s current abilities and expected potential. If there is a difference between current state and potential future state, you must explain why that is the case.
• Bilateral amputees often cannot be strictly bound by the functional level classifications.

What This Means for You:

There are 4 key takeaways related to K-levels.

First, potential remains an inseparable component of functional level analysis. As a result of aggressive auditing activities over a decade ago, many prosthetists today remain focused only on a patient’s current state. However, focusing exclusively on an amputee’s current ability ignores the express language of the LCD, which permits – and arguably encourages – consideration of their potential in the future. To make sure your patients get what is best for them clinically, do not ignore their potential. Document in detail those facts supporting your conclusions about their potential and make sure the prescribing physician does the same.

Second, pay close attention to the use of articles in the K1-K4 functional levels. For example, a K1 individual doesn’t have to have the ability/potential to both transfer and walk on level ground. The “or” shows that either one standing alone is sufficient to satisfy K1 requirements. The K2 definition similarly uses the word “or” when it mentions navigating specific low-level environmental barriers. If your patients can do any one of those activities, that is consistent with K2 classification. Note also the use of “or” in the K3 and K4 levels.

Third, the facts supporting your functional level determination are arguably the most important part of your clinical documentation. Be detailed. Get complete histories from your patients. Explain why even though a patient may only be a limited community ambulator today, they’re likely to be an unlimited walker three months from now. And make sure that you work closely with the prescribing physician so that there is a shared understanding of those facts and the physician corroborates your findings in their own medical record.

Finally, when treating bilateral amputees, know that if you want to provide them components outside of their functional level, you can do so. However, you will need to provide detailed justification supporting your conclusions. While bilateral amputees “often” cannot be bound by the functional levels, that means sometimes they can. You want to make clear in your notes why the existing functional levels do not apply in a specific case.

Next in this series: General section of the LCD.