Hello Everyone,
I have a question regarding Medicare benefits and coverage when a patient
has recently received a Power Mobility Device (Scooter, electric wheelchair,
etc.) and now are wanting to also have a prosthetic leg. Do you provide
services to these patients? Do you get paid? Have you been audited on
these claims?
The reason I am asking is because I currently have a patient who recently
received a scooter AND is now in the process of getting a prosthetic leg
(above the knee). She originally started the process at another facility
which is much closer to her home. For some reason (unknown) she quit going
to them and came to my office to get this leg. I always ask the patient
about if they have gotten any kind of power mobility device, AND I also
check the website/portal/connex, etc. to see if Medicare (or private
insurance) has paid for any of these items recently. BUT since Region B is
now with CGI, I still have not gotten my password and username to get onto
their system/website to check on this patient. (That is ANOTHER story that
I should share here…maybe another day..)
In her chart notes from the doctor, it states clearly that this patient is
afraid to use her new scooter because it is top heavy and she is afraid that
she will fall over with it and get injured. The Physical Therapist also
documented something about her new scooter. When I asked the patient again
about if she has a scooter, she said “NO” and then I showed her the doctor’s
notes, and she looked puzzled and said she had no idea why the doctor would
write something like that. THEN her daughter gave her the evil eye, like
“tell the truth” kind of look at her mother, and then she said that she DID
have a scooter, but it is NOT an “electric wheelchair” and then she also
said her husband paid cash for this. I called the doctor’s office and
finally was able to find out WHO provided this scooter (where they sent the
referral and chart notes). I called this company to ask them, and only
found out that this company is closed and out of business. (I actually
ended up calling the stores that were near this office to ask if they were
still at this address, both of the businesses I talked to told me that the
company closed and quit, and is no longer at this location.) The phone
numbers of this company say that they are no longer in service, to check the
number and try again….
I cannot get online to check if this is true or not. I SHOULD be online
with CGI sometime in the next week or so. This should have been set up
MONTHS ago,
Also, about 3 years ago, I had another patient who was a high K-3 level
amputee who enjoyed going mushroom hunting (hiking trails in the hills and
woods in southern Indiana), he also was a mechanic and did heavy lifting and
other jobs like that. I had NO reason to even THINK that he would have an
electric wheelchair. I made him a new leg, a physical therapist did the
mobility predictor for him, he had a high K-3 score. The physician also
noted that this man was a strong and healthy male who did heavy lifting for
his work, etc. BUT some doctor a few months prior to this said that this
man had no potential to ambulate, his upper body strength was horrible, he
could not propel a manual wheelchair due to his overall weakness in his
body, etc. He qualified for a “power mobility device” and Medicare paid
for a nice scooter for him from one of these stores who advertised on TV to
get a scooter “At little or no cost to you”…. He uses this scooter in
places like Walmart, Flea Markets, the Theme Park nearby, county fairs, etc.
(I know this is NOT the intended use for a power mobility device as Medicare
states in their policies….it is for in-home use only).
Anyway, I had a pre-payment audit on this claim, and it was denied because
he had recently gotten this PMD. It was determined to NOT be medically
necessary for him to have a prosthetic leg. They stated that this man had
no ability or potential to walk according to the documentation received by
Medicare with the paperwork for him to get this power wheelchair. So, they
stated there is no way that this man could be a K-3 level amputee and the
ability to perform at K-3 levels. I stated that a physical therapist, who
is in no way connected to my business, who has NO vested interest in my
company, is the one who determined this score. This patient does all kinds
of activities where he NEEDS a prosthetic leg so he can walk, work, and do
all of the things that he does. Medicare (NGS) did not budge on this issue
and stated that they will not cover the prosthetic leg since he had recently
gotten this PMD. I do not know if they went after the company that
provided the wheelchair/scooter to him and got their money back from them.
I can totally understand when Medicare gets this kind of information saying
the patient cannot even stand or walk at all, and then at the same time
another set of documentation stating that he walks with NO limitations at
all. WHO do they believe??? How can they trust either of us???
So I have basically made it my policy to NOT provide any prosthetic services
to patients who have recently gotten any kind of power mobility devices. I
am wanting to know from others what they are doing in these situations.
How do you get paid for any prosthetic leg for a patient when the
documentation for the PMD states the patient has no ability to walk at all,
but to be even at a K-1 level amputee, they need be able to at least walk on
level surfaces at a fixed cadence, etc.
The bottom line is this: do you provide services for patients who have
recently received any power mobility device through Medicare? Have you
gotten paid? Have you been audited on these claims? Have you had to pay
money back in a RAC audit for any of these situations? I am now working
with CGI for Region B Medicare. NGS is no longer in the picture here. What
has CGI (Region C) done in these situations? Does anyone have any experience
with CGI regarding PMD and Prosthetic legs?
Thanks
Jim DeWees, CP
