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Linda Collins Blogger

Prosthesis Replacement

Posted by Linda Collins | July 14, 2015

Your patient has been on the same prostheses for several years now. The current device is no longer meeting the patient's needs. When and how do you bill for a replacement prostheses?

Medicare may pay for a replacement prostheses when the ordering physician and prosthetist determine the replacement is reasonable and necessary. Documentation in the physician's and prosthetist records must support one of the following conditions:

  • A change in the patient's physiological condition such as weight gain/loss;`
  • Changes in the residual limb;
  • Changes in the patient's functional level;
  • Repairing the original device will cost more than 60% of the cost to purchase a new device (See 60% of What); OR
  • The device is irreparable, with supporting documentation

A replacement prosthesis requires a new Detailed Written Order (DWO) and physician medical records that explain the reason for replacement. The prosthetist must also document the reason for replacement in the patient's medical record. It is important to be specific and detailed about the reason for replacement. Photographs of a broken component or ill-fitting socket can help with that justification. (NOTE: If you do take photographs, be sure to identify the patient and date on the back.)

You may also be required to provide supporting documentation which indicates the patient's functional level. For example, if the patient previously had a MPK designated for K3 users or above, you must prove the patient is still a K3 user in order to put a new MPK on the patient.

As is the case with all prostheses, the right (RT) and left (LT) modifiers must be used on the claim. K0-K4 modifiers will also be required.

The LCDs for Lower Limb Prostheses can be found through the following links:

Region A, NHIC, LCD

Region B, NGS, LCD

Region C, CGS, LCD

Region D, Noridian, LCD

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