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David McGill Blogger

Back to Basics: The Prosthetic LCD (Part 1)

Posted by David McGill | August 14, 2013

​Given the generally poor prepayment claim review results that have rolled in from the MACs over the last year, we think that doing a multi-part refresher on the key elements of the Lower Limb Prostheses LCD is in order. 

This is basic, basic stuff. That being said, it appears a significant percentage of audit and prepayment claim review denials arise out of suppliers' failure to get the basics right. 

So without further ado, let's tackle Part 1.

​DWOs, "Reach or Maintain," & Motivation

You should know 3 things about the first section of the LCD.


  1. It states that you must have a detailed written order from the physician before you submit the claim. For those of you breaking into a cold sweat thinking that this requires the doctor to fill out yet another document with a million pieces of information, take heart: Medicare policy explicitly states that the supplier - YOU - can fill out the form in its entirety and simply get the physician to sign and date it. For an exemplar DWO, go to "Reimbursement Resources" on the left side of the Ossur R&R webpage and click on any of our product Reimbursement Guides, each of which contains a model DWO.
  2. It states that a lower limb prosthesis is covered when the beneficiary will reach or maintain a defined functional state within a reasonable period of time. What's a "reasonable period of time?" Medicare doesn't provide any guidance in the LCD, so you'll have to employ a common-sense approach based on your experience and risk tolerance.
  3. It states that a lower limb prostheses is covered when the patient is motivated to ambulate. We've heard repeated instances of Medicare denials based on the absence of documentation establishing this fact. As basic and implicit as this is, both your notes and the physician's should confirm whether the patient is motivated to ambulate. 
In part two of this series we'll focus on the LCD's discussion of functional levels.


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