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Linda Collins Blogger

Documentation of Replacement Prostheses

Posted by Linda Collins | May 22, 2018

According to CGS Medicare, Jurisdiction C, the number reason for claim denial for prosthetic claims is a lack of or insufficient physician documentation supporting the new for replacement.

Any claim involving the replacement of a major prostheses (foot, ankle, knee, 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 prostheses 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)

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