Thank you to everyone who responded…..
Original Email:
I have a patient that just received a power wheelchair and they also want a
prosthetic device (K2, Above Knee Amputation, Medicare is the primary
insurance, medicaid secondary). I am not able to find any information as
to if they can have both. According to the Medicare representative I spoke
with, it is all based on medical necessity. When I asked for examples of
what would qualify a patient for both, the representative only said it
would be determined at the time the claim is submitted. I’m concerned it
would be an automatic denial and have to go through the appeals process.
Any thoughts, advice or experiences would be greatly appreciated.
Responses:
1. The two items are not mutually exclusive to one another. A patient
can have both, based upon medical necessity.
However, I would highly suggest you have the prescribing MD include in the
patient’s file a very strong argument for both.
What we do in our office is we educate the physician and help them with
their clinical notes to include language that medicare understands.
K level, motivation, reasons for both wheelchair and a prosthesis are all
in the MD clinical notes. We usually work with someone in the MD’s office
who can get this done. Use the AMPRO predictor and have the MD sign off on
it. Include this with your medical records.
Expect a denial and be prepared to fight it. If the MD clinical notes are
good you will be fine.
2. Pt is NOT K2 ambulator with PWC. MOF, he or she signed paper stating
that he is either non ambulatory OR very limited ambulator, to qualify
for PWC. So did MD, who signed off on PWC p/w. You can do it with a K2 but
absolutely not for a K3
3. Always risky as it is based upon medical necessity. Patient ‘wants’
doesn’t cut it. You and physician (physiatrist preferred) must document
specific activities that can and can’t be performed with power chairs.
This may be navigating narrow doorways in home like getting into bathroom.
A lot of chair manufacturers prohibit their chairs for outdoor use. Steps
in home? Participating in physical therapy? Other activities? Physician
recommended exercise program?
AMP-PRO or AMP-NOPRO done by PT that will be working with them to determine
K2 potential. Goals and outcomes.
4. There is no direct policy on having both. The issue is to qualify
for a wheelchair the patient has to be documented non-ambulatory. To
qualify for a prosthesis you must document the patient as ambulatory. If
Medicare has documentation the patient is not ambulatory and has already
paid for equipment as such you now have the uphill battle to prove the
ambulatory status of the patient and be willing to go through the appeal
process to prove it. Your documentation must be very convincing to
override all of the documentation needed to get the wheelchair.
5. It is not an automatic denial, but the kicker is this. In order for
a patient to get a power chair, they sign paperwork and attest to the fact
they are non-ambulatory and do not have the potential to ambulate. So if
you deliver a device make sure you get documentation from Dr. and PT on L
lvl. That way if it gets audited you have evidence.
6. My understanding is that they cannot have both. We’ve talked to some
therapists who do powerchair evaluations and in order to qualify for a
powerchair they cannot be ambulatory enough to be a K2, in the paperwork
for the wheelchair it probably shows that they are not ambulatory. The only
chance you have it to do an AMP Pro done by a doctor or therapist. But if
the powerchair is rental – which most are- the patient will probably loose
the powerchair.
7. They are able to have both as long as the wheelchair is not a
specific type (sorry, I’m not at my office to give the exact codes, but can
get it for you on Monday) These specific types, the physician had to
write that the patient will never be able to walk again.
8. If you don’t have a pre-auth, then don’t start the work. If they
have both MCare and MCaid, they probably have a TPA that will give you the
pre-auth. Get it in writing.
9. If you don’t have doctor’s chart notes that ensure necessity, then
you may not get paid. Again, don’t start the work until you have
everything you need to get paid. Unless you plan to donate the work.
10. I’m assumption is a power wheelchair =K1. Now if you coded a K2 and he
never achieves that and then get a power W/c. You may not lose the audit
but will only be able to code him as K1 unless you can prove otherwise….
you will likely be audited either way.
11. I have always been concerned about providing a prosthesis for a
patient who has a power chair because of the paperwork necessary to get a
chair covered IE it has been documented that the patient is non-ambulatory
and lacks function to use a conventional chair; however I have provided
numerous devices in this situation and never had a denial. Make sure you
have detailed clinical notes from the doc concerning why it is medically
necessary for the patient to have the prosthesis AND the chair and you
should be good to go.
12. My experience time after time is…power wheelchair = NO Orthotic OR
Prosthetic services. You can take a chance but you’ll fail the RAC audit
EVERY time.
13. Put a dog in the fight. Have the pt sign an ABN based on unknown
required qualifications. Good luck.
14. I would suggest having the patient sign and ABN and if your Medicaid
program doesn’t have any exclusions you should be able to bill them. In
Massachusetts we can get a PR denial from Medicare and have MassHealth pay
a claim as long as it meets their regulation.
15. I have never provided a prosthesis AFTER one has received a power w/c
from Medicare. I have seen AK prosthetic users obtain a power chair AFTER
having used their prosthesis for a few months. The medical justification
was “long distance” ambulation is difficult, they cant keep up with family
members, can’t enjoy amusement parks as they heave their entire life.,
hardship on family members….rationales like that.
—
*Stephanie Sheedy*
President
Monroe BioTechnology, Inc.
920-435-3002
https://urldefense.proofpoint.com/v2/url?u=http-3A__www.monroebiotech.com&d=DwIFaQ&c=sJ6xIWYx-zLMB3EPkvcnVg&r=KmuawjwNpT9A2bnhzaNVjw8wO7L_TDosEXIk33h_tlw&m=xp8-Q_h7XKsLv5EpnX_A6UWlLqA0axCinXtVYi06aOA&s=jvbvgtWge4PnWoQvcqaA05_XR3v1MLpTbIOi-jDE9I4&e=
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