Geriatric Patients: Are They Getting the Best Prosthetic Choices?

Classifying geriatric patients appropriately is crucial to providing beneficial components. Most patients currently needing prosthetic care in the United States are geriatrics. I estimate that 70 percent of the patients seen by most practices are geriatrics, and the percentage is probably higher in areas such as Florida where there are large retirement communities. The prostheses for these patients are reimbursed through Medicare, which requires that patients be classified in one of five categories according to their POTENTIAL of functionality. Developed by Medicare's legal experts and endorsed by the government with very little input from our industry, these functional classifications contain some vague wording which could result in a patient being placed in an inappropriate category. Since the types of components that will be reimbursed for a Medicare patient are dependent upon this classification, whether the patient is classified correctly is significant. In an effort to ensure that geriatric patients are provided with the components they need in order to live their lives to the fullest, let's examine each of these five categories and address areas of concern. The regulations require the category classification to be determined by the prosthetist and attending physician coming to agreement regarding the patient's potential. In most cases the physician relies very strongly on the prosthetist's recommendations. Often, the patient may not realize that these professionals actually determine and establish the patient's classification category. It is interesting to note that therapists, both physical and occupational, as well as the social worker, case worker, or anyone else who works with the patient, are not considered. If the prosthetist and the physician are wise, they will request and consider input from the therapists when making their decision. Category 0 Category 0 is a patient who is not a prosthetic candidate--who usually is bedridden or has no ability to stand up. Medicare will not reimburse for any prosthetic work done for this patient, even if the patient has complete Medicare coverage. Category 1 "Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator." This classification indicates that the patient has the ability (or the POTENTIAL to have the ability) to use the prosthesis for transfers from one place or chair to another and to walk on level surfaces, such as floors at home at just one speed--usually very slowly. This type of patient has typically been classified as a "household ambulator." Active geriatric patient, Isadore Neuman, and his wife, Laverne, enjoy an outing. Photo courtesy of Ohio Willow Wood This suggests strongly that the patient doesn't go outside of the house to uneven terrain, uneven sidewalks, or anywhere there are slopes and surface irregularities. It suggests that people use a wheelchair for such situations and only use their prosthesis indoors in a confined level-floor situation. People in this category cannot be reimbursed for energy-storing feet, hydraulic knees, or any knee system that might employ higher or newer technology for the use of fluid control to prevent stumbling. It seems ironic that if the patient is classified at this time as only having the ability to be a household ambulator, then we will never really know if the patient has the potential to move to the next level with the aid of more high-tech equipment. Category 2 "Has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator." In this category, Medicare expects the patient to have the ability, or at least the potential, to go outside into the community and be able to handle such barriers as stepping up onto curbs, stairs, and uneven surfaces. There are no restrictions as to the patient using additional walking aids such as crutches, canes, or walkers to achieve this goal. Patients are free to use any of these as long as they can fill the requirements stated above. Over the years I have found that prosthetists tend to quickly classify their geriatric patients into category 1 or 2. Certainly most geriatrics can fill the requirements of category 2, however, many in reality could reach category 3. Category 3 "Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion." These patients have the ability or the "potential" to reach out and achieve not only the requirements of being a community ambulator, but also the ability to walk at a variable cadence. Many prosthetists assume that variable cadence means running or jogging. In this writer's humble opinion, that is not correct. Variable cadence to me does not necessarily mean one who is running or jogging, but rather one who can ambulate at more than one speed. We have seen many geriatric patients who walk slowly, but can walk much quicker if they are crossing the street and need to get out of the way of an oncoming vehicle. Even though they may use a cane or other assistive devices to give themselves additional support, either physical or mental, many older patients can walk at what they consider to be their normal speed, but when crossing a street can vary that cadence to a higher speed for safety reasons. To me, this is a demonstration of variable cadence. Components that are reimbursed for Category 3 patients include fluid-controlled knees, which easily allow for achieving variable cadence of the knee, and energy-storing feet, which provide additional energy to move quicker when necessary. Potential--or Demonstration? A perceived "Catch 22" of this category is that many prosthetists feel that the patient must demonstrate the ability for variable cadence prior to receiving and billing for these components. However, it is far easier for the patient to reach this level of activity with these components than without them. Prosthetists commonly interpret this classification to mean that the patient must demonstrate the ability before becoming eligible for this additional prosthetic equipment. That is not my interpretation of what is written in the Medicare requirements. Once again, we seem to gloss over the word "potential" and substitute the word "demonstrate." My understanding after much discussion with the people at Medicare is that the patient must have the potential to be able to arrive at this level of ability after having used these components. Medicare indicates that the patient should be able to demonstrate this ability within a reasonable period of time after receiving these components. Medicare has suggested that a "reasonable period of time" is one year. We in the prosthetics industry need to understand that the patient simply has to have the potential for this category at the time of prosthesis application. Using these components to complete the requirement of variable cadence then makes the patient eligible for these services. The second part of this classification, which states that the patient "may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion," also merits attention. I'd like to focus on the word "may" and point out that it is clearly not "must." Many of the geriatric patients who are using prostheses also have some cardiac restrictions or concerns and may have suffered a cardiopulmonary episode that unfortunately goes along with the disease that most likely caused the loss of the limb. Therefore, it is not uncommon for attending physicians to encourage the patients to continue to "exercise" and to continue with cardiac rehabilitation. That exercise/rehabilitation often involves walking, bicycle riding (either stationary or mobile), golfing, bowling, and other low-stress activities in which geriatric patients can participate. Many geriatrics may also have part-time employment requiring they remain standing for periods of time. In these types of activities, we see that the geriatric patient requires the use of energy-storing feet as well as fluid-controlled knee stability. Patients wishing to continue with this lifestyle greatly need these prosthetic items. In order for these components to be reimbursed, the patients must fulfill or have the "potential" to fulfill the requirements of this functional classification. We in the prosthetic industry have been shortsighted and have overlooked the words "have the potential" as well as the words "may have the need," as clearly stated in this classification. Because of this, many older patients are denied these services. Prosthetists need to be aware that if these patients have the potential to arrive at this level of activity, and if the prescribing physicians agree, then the patients are clearly entitled to have this equipment. It has been my experience that a well-documented file demonstrating that the patient does have this potential is all that Medicare requires for financial reimbursement. Category 4 "Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete." This level is clearly outlined for the athlete. Very few older patients fall into this category--however, there are some. Most of these are healthy individuals who have undergone amputation at a much younger age and have continued to be athletes. By "healthy individuals," I mean they did not undergo amputation because of medical reasons such as vascular disease, diabetes, or cardiopulmonary insufficiency, but rather due to trauma. Even though they may fall into the category of geriatric (65 years or older), they are still quite young at heart and physically fit. These individuals may participate in tennis, jogging, or a number of other strenuous activities. Once again, we notice the words "have the potential" to arrive and/or maintain this level of athletic activity. There are very few items (mainly feet) that are classified as Level 4. There are no knees that I am aware of in this category. We need to point out that an amputee at higher level--for example a Level 4--can use anything in a Level 4, 3, 2, or 1. The amputee is eligible for anything in his category and lower. However, he cannot move to a higher category without first being established as qualifying for that category. Summary Patients who have the potential to upgrade or improve their activity have one year's time to achieve this. At the end of that year, the prosthetist should document in the patient's file that the patient is doing the activities expected and is fulfilling the potential of the category in which he has been placed. I feel many older amputees are not getting the type of prosthetic devices that would benefit them the most because they are not properly categorized. Prosthetists are afraid to reach out and place them in a higher category, lest Medicare rebel. The prosthetist must look at all of the potential abilities of the patient, discuss them at length with the prescribing physician, and come to a realistic assessment of that potential. Many older patients can be provided with the tools to make their lives more meaningful and enjoy some of the newer technologies now available to the amputee community. Raymond Francis, CP, is a certified prosthetist with over 40 years experience. His patients have included amputees of all ages and activity levels ranging from older, less active amputees to active-duty military. He is the chief prosthetist for Ohio Willo

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