Q: I work for an O&P facility in Oklahoma. I have a situation that I have never come across before. A practitioner in our clinic made a transtibial prosthesis for a Medicare patient. The prosthesis was ready for the patient to pick up, and we tried calling the patient several times with no response. We received a call from the patient’s son stating his father passed away. Now we have a custom prosthesis that we made, but we don’t know how to get reimbursed since the patient never received the device. Any assistance is greatly appreciated.
A: According to the Supplier Manual, Chapter 5, DMEPOS Fee Schedule Categories Artificial Limbs, Braces, and Other Custom-Made Items Ordered but Not Furnished: If a custom-made item was ordered but not furnished to a beneficiary because the individual died, payment can be made based on your expenses. In such cases, the expense is considered incurred on either: The date the beneficiary died; the date that you learned of the cancellation of the item; or the date that you learned that the item was no longer reasonable and necessary or appropriate for the beneficiary’s condition.
The allowed amount is based on the services furnished and materials used, up to the date you learned of the beneficiary’s death or of the cancellation of the order or that the item was no longer reasonable and necessary or appropriate. The DME MAC determines the services performed and the allowable amount appropriate in the particular situation, taking into account any salvage value of the device. If you breach an agreement to make a prosthesis, brace, or other custom-made device for a Medicare beneficiary, e.g., an unexcused failure to provide the article within the time specified in the contract, payment may not be made for any work or material expended on the item.
Whether a particular supplier has lived up to its agreement, of course, depends on the facts in the individual case. To read the complete policy in the Summer 2021 Supplier Manual, visit bit.ly/3t18Asa.
Q: I am a prosthetist in Georgia. I have a patient who has had his prosthesis for five years. He lost about 50 pounds, and the device no longer properly fits him. I know for orthoses Medicare states how long a patient has to have a brace before it can be considered for replacement. Is there anything specific Medicare mentions when it comes to a prosthesis?
A: There is no time frame that Medicare indicates as the reasonable useful lifetime (RUL) for prosthetic devices. Replacement of a prosthesis or prosthetic component is covered if the treating practitioner orders a replacement device or part because of any of the following: A change in the physiological condition of the beneficiary; or irreparable wear of the device or a part of the device; or the condition of the device, or part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or of the part being replaced. Replacement of a prosthesis or prosthetic components required because of loss or irreparable damage may be reimbursed without a practitioner’s order when it is determined that the prosthesis as originally ordered still fills the beneficiary’s medical needs.
I recommend you ask the physician for detailed records outlining the reason for the replacement, the functional level of the patient, and the continued need for the device. Always use the RA modifier and any other modifiers, such as RT, LT, or K-level. To access the complete policy on adjustments, repairs, and replacement, visit go.cms.gov/3gPC40C.
Lisa Lake is an independent medical consultant with over 25 years of experience in the O&P industry, increasing providers’ revenue by product recommendation, product and billing knowledge, and contract access assistance. She is a nationally recognized speaker on billing reimbursement and government compliancy. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. Lake can be contacted at [email protected]
