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PRESENTED BY: Aaron Sorensen, MBA, CPO, LPO
O and P Billing Solutions, Inc.
- Brief overview of proposed prosthetic changes
- Actions that need to be taken - Prior to Aug 31, 2015
- Discussion of preparation - Positives to get your practice
prepared for changes
July 16, 2015 CMS announced
proposed extreme regulatory changes to LCD
Link: http://www.medicarenhic
.com/viewdoc.aspx?id=3109&utm_source=%C3%96ssur+R%26R&utm_campaign=d9cb33f080-Huge+Changes+for+Prosthetics%3F+The+New+Draft+LCD&utm_medium=email&utm_term=0_bc41d72a42-d9cb33f080-18696049
Far reaching Consolidation of codes New definitions of
functional levels Using “bundling” an
“unbundling” terms Defining level of
prostheses based on path from surgery
Newly described face-to-face requirements
Approved rehab programs
Consolidation of code s
KXXX1 ALL LOWER LIMB EXTREMITY PROSTHESES, FOOT, DYNAMIC RESPONSE
New code
KXXX2 ADDITION TO LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR WITHOUT ADJUSTABILITY
New code
L5970 ALL LOWER EXTREMITY PROSTHESES, FOOT, EXTERNAL KEEL, SACH FOOT
Narrative revised to: ALL LOWER EXTREMITY PROSTHESES, SACH FOOT, REPLACEMENT ONLY
L5971 ALL LOWER EXTREMITY PROSTHESIS, SOLID ANKLE CUSHION HEEL (SACH) FOOT, REPLACEMENT ONLY
Discontinued CROSSWALK TO L5970
L5974 ALL LOWER EXTREMITY PROSTHESES, FOOT, SINGLE AXIS ANKLE/FOOT
Unchanged
L5975 ALL LOWER EXTREMITY PROSTHESIS, COMBINATION SINGLE AXIS ANKLE AND FLEXIBLE KEEL FOOT
Discontinued CROSSWALK TO L5974
L5976 ALL LOWER EXTREMITY PROSTHESES, ENERGY STORING FOOT (SEATTLE CARBON COPY II OR EQUAL) Discontinued CROSSWALK TO KXXX1
L5978 ALL LOWER EXTREMITY PROSTHESES, FOOT, MULTIAXIAL ANKLE/FOOT Unchanged
L5979 ALL LOWER EXTREMITY PROSTHESIS, MULTI-AXIAL ANKLE, DYNAMIC RESPONSE FOOT, ONE PIECE SYSTEM Discontinued CROSSWALK TO L5978
L5980 ALL LOWER EXTREMITY PROSTHESES, FLEX FOOT SYSTEM Discontinued CROSSWALK TO KXXX1
L5981 ALL LOWER EXTREMITY PROSTHESES, FLEX-WALK SYSTEM OR EQUAL Discontinued CROSSWALK TO KXXX1
L5982 ALL EXOSKELETAL LOWER EXTREMITY PROSTHESES, AXIAL ROTATION UNIT Discontinued CROSSWALK TO KXXX2
L5984 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESIS, AXIAL ROTATION UNIT, WITH OR WITHOUT ADJUSTABILITY Discontinued CROSSWALK TO KXXX2
L5985 ALL ENDOSKELETAL LOWER EXTREMITY PROSTHESES, DYNAMIC PROSTHETIC PYLON Unchanged
L5986 ALL LOWER EXTREMITY PROSTHESES, MULTI-AXIAL ROTATION UNIT ('MCP' OR EQUAL) Discontinued CROSSWALK TO KXXX2
L5987 ALL LOWER EXTREMITY PROSTHESIS, SHANK FOOT SYSTEM WITH VERTICAL LOADING PYLON Discontinued CROSSWALK TO KXXX1
L5988 ADDITION TO LOWER LIMB PROSTHESIS, VERTICAL SHOCK REDUCING PYLON FEATURE Unchanged
Overview of these changes: The medical
director(s) clearly do not know what these codes are or are used for
i.e. MCP or equal is not the same as axial rotation!
Government has a system in place for establishing new codes for new products
No new code can be established without being scrutinized by government
These codes have already been scrutinized and were determined they were not significantly the same as established codes!!!
Products were vetted by government established system and it was decided a new code and new reimbursement level was needed! Not the O and P industry
making the definitive decision, but the government system
K-level re-defined (again) Now potential removed
form the definition Utilizes assistive devices to
define the K-level which overrides the definition
K1 - Use of a walker or crutches while using a prosthesis results in a K1
K2 - Use of a cane while using a prosthesis results in a K2
K3 - Does not require the use of any mobility assistive equipment such as a cane, crutches, walker, or wheelchair.
Does any prosthetist have a patient that: May use a cane in some
circumstances and a walker in other? K1 or K2?
May use a cane/walking stick in some circumstances and nothing in other? Unleveled ground for
prolonged ambulation (hiking) While carrying items
(backpack, bags, boxes under arm, etc.) for balance
Does this prevent the pt from also ambulating with variable cadences at other times?
Or ability to traverse most (not all) environmental barriers without physical or safety concerns
K2 or K3?
Functional level assessment must conclude: The prosthesis
provided must provide:
Stability, Ease of movement, Energy efficiency, and The appearance of a
natural gait
WHAT? REALLY?!
They want to reference studies and lack of studies for these LCD changes
The medical directors are doctors
And they want to use the previously stated criteria? Will a bilateral have ease of
movement, energy efficiency and a natural gait?
What is a natural gait? People with two sound limbs vary in
gait Have they not studied or seen
studies for energy expenditures due to amputation!
Again, how possible is this with the prosthetists’ hands tied on bundled IPOP and preparatory prostheses?
In-Person Physician Patient Examination Required
Any patient receiving a definitive prosthesis is required to complete an in-person examination by the physician Before physician signs the
detailed written order The physician must provide a
copy of examination to the prosthetist within 45 days and:
Provide the copy before delivery of the prosthesis.
It sets out a list of comprehensive testing that must be completed and included in the in-person examination report.
Bundling and Unbundling?!
Used in other areas of medical billing
All-inclusive verbiage Now used for several
areas of prosthetics Initial and preparatory
prostheses are now all-inclusive base code
No additions allowed Will be denied as not
reasonable and necessary Hello SACH feet!
Current LCD states initial and preparatory prostheses are permitted to use substitutions and additions in accordance with functional level assessments with defined exceptions.
Now they are stating functional levels are not pertinent in these levels? All patients are a K1?
Patient amputated from trauma (car wreck) treated same as pt with PVD and diabetes?
These were CMS decisions for decades, now they are stating their policies were wrong?!
Pre-determined prosthetic pathway New amputee - prosthesis
must be preparatory Residual limb not mature
An initial prosthesis is defined as the first (initial) prosthesis reimbursed by Medicare. This includes (1) a prosthesis provided for the first
time after an amputation that occurs during the beneficiary’s Medicare eligibility and
(2) “replacement” of an existing prosthesis obtained prior to or outside of the Medicare program.
Each new, initial prosthesis claim must meet all applicable Medicare payment rules for an initial prosthesis in effect on the date of service of the initial claim. These requirements are
extensive!
Definitions needed Healed? Only relating to suture
line status? Pain? Swelling? Pressure sensitive?
Mature? No more shrinking? Atrophy different that
swelling, correct? What are they talking
about?
Prosthetic Rehab Program
Problems with the “defined program” Have sufficient wear
tolerance to use the prosthesis for a normal day’s activities.
Attain sufficient balance and stability to ambulate with ease of movement and energy efficiency with the preparatory prosthesis after final residual limb volume stabilization and prior to provision of the definitive prosthesis
WHAT? REALLY? Define NORMAL day activities?
For a person with two sound limbs? For a bilateral amputee? For a unilateral AK? For a unilateral BK?
Define Sufficient? Wear tolerance, balance, stability? For who? Depends on K-level?
With energy efficiency On a prosthesis utilizing NO
ADDITIONS! SACH FOOT No alignment changes Poorly fitting socket What the heck are they thinking? They do not want to pay for
prosthetic advancement!
Other changes No more prosthetic
exception during SNF stay
Denial of vacuum systems and quick change units
Repair codes high level of definition
Liner discussion and duplication definition (bundling)
Ultra-light materials, covers and alignable system codes more finely defined
Suction suspension now tied to K-level
Review the policy proposal in its entirety
DO NOT relate on the various emails and postings that have been sent out
Tremendous amount of information
Each practice will be affected differently depending on your business and clinical model
E-mail HHS Secretary Sylvia Burwell, not the DMEMAC, http://www.hhs.gov/contactus.html
Easily access the petition at //www.saveprosthetics.org.
Contact local TV, newspaper, bloggers, community clubs (Lions club, Key club, etc.).
Encourage patients to share the online petition with their family, friends, support groups and other healthcare professionals.
Ask patients to sign the online petition while they are in your office.
Have each patient sign the petition and fax it to their Senators and Representatives.
Submit comments through http://aopavotes.org/
Use #NotaLuxury in your social media.
Post info about this in your offices and other healthcare professionals offices.
90 day time limits provided for replacements
K-level potential removed As pt progresses you
can re-evaluate and document K-level changes for advancing the pt upward
Develop relationships with PT groups
Acknowledge the use and acceptance of templates
Start analyzing your clinical protocol
Start searching for PT referral sources/develop relationships/SOPs
Read proposed changes and develop templates to meet documentation requirements
Start conversation with your chosen mfg and distributor on cost effective components/options
Develop plan for educating your: Patients Referral sources Staff
There is a tremendous amount of info that could not be covered in 50-55 minutes
Please take this time to ask questions regarding: Any proposed changes
we did not cover What can be done prior
to Aug 31 Practice preparation Anything else!
THANK YOU Freedom Innovations
thanks you for your continued support and hopes this series of webinars helps you navigate the tumultuous environment of serving MEDICARE PATIENTS.
Aaron Sorensen, CPO, LPO, President OPBS [email protected]
Ph. 877-907-4180
Please provide feedback to your Freedom sales representative of future topics to cover and if you find these webinars helpful.
Next webinar: September 25, 2015 Marketing to patients
Rob Cripe, VP Global Marketing
Ph. 949-544-7916
