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David McGill Blogger

Back to Basics: The Prosthetic LCD (Part 2)

Posted by David McGill | August 15, 2013

Functional Levels

Functional level denials comprise a statistically alarming percentage of negative audit and prepayment claim review findings. In many ways, this has become Ground Zero in the documentation war between prosthetists and Medicare. 

The LCD states that potential functional ability "is based on the reasonable expectations of the prosthetist and treating physician." Medicare takes the position that this language therefore requires solid functional level documentation in two different places: (1) your records, and (2) the doctor's records.  

​The LCD lists several factors as examples of relevant data when making functional level determinations:

 

  1. The patient's past history (including previous prosthetic use, if any);
  2. The patient's current condition, including the status of the residual limb and any other medical problems; and
  3. The patient's desire to ambulate. (Covered in Part 1 of this series.)
The LCD then defines each functional level. While you should review the complete definitions yourself, they can be summarized as follows:
  • K0 - non-prosthetic user
  • K1 - household ambulator
  • K2 - limited community ambulator
  • K3 - community ambulator (potential or actual variable-cadence walker)
  • K4 - high impact, high stress, high energy level user.
The functional level section concludes with two reminders:
  1. "The records [again - based on current Medicare policy, you should assume this refers both to your and the doctor's records] must document the beneficiary's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case." 
  2. "Bilateral amputees often cannot be strictly bound by functional level classifications." (With that being said, we've heard anecdotal evidence that Medicare has increasingly resisted prosthetist's functional level categorizations for bilateral amputees, this directive notwithstanding.)
In Part 3, stay tuned for how the LCD addresses prosthetic feet, knees, ankles, hips, and sockets. 


 

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