Thanks for all that have responded with their helpful suggestions. Below is
my original plea for help and then the responses I received. Please feel
free to add to this if you see something not touched in these responses.
Again thanks for all the help!
Original post:
I am looking for any help in fighting an appeal for the L5981 code that we
used for a foot from a delivery in Jan. 2012. We are in the second stage of
the denial. Any ideas or help would be so greatly appreciated. They state
that the claim is not covered by Medicare. I am sure this type of question
has been posted before. If so, is there a way I can easily look up the past
responses on the list serve? If not, I still need help in fighting this BS!
I have submitted all the good stuff from the physician, and a supporting
letter from the physician stating that the patient still is and was at the
time of delivery a functional level 3 amputee. At the time of delivery in
Jan. 2012, I had no knowledge that the good stuff had to be in the
physician’s documentation. Anyways, any good ideas going forward with this
fight?
TIA!
Jim Sedlak, CP
Prosthetic HealthCare Services
Kearney, NE
Responses:
Hello all,
I wanted to share a helpful tip I encountered during a recent RAC audit.
During the ALJ hearing, I pointed out that the LCD insinuates that it can be
the physician OR the prosthetist that documents and determines the
appropriate componentry (knee and feet) of the prosthesis. The LCD (L11453)
states “a determination of the type of knee for the prosthesis will be made
by the treating physician AND/OR the prosthetist based upon the functional
needs of the beneficiary.” It goes on to say “this information must be
retained in the physician’s OR prosthetist files.” Never does is say that
functional levels and components MUST be documented by the physician. By
highlighting the “or” verbiage within the LCD, the judge agreed that this is
ambiguous and providers can interpret this to mean that the prosthetist can
be the only one to determine the proper knee or foot according to their
functional level assessment; ultimately meaning that the physician is NOT
required to document the necessity of the knee or the feet. This analysis
was successful and the judge agreed that physician documentation concerning
the functional level and prosthetic components is NOT required to determine
medical necessity.
In addition, the Medicare Supplier Manual also states that the patient’s
medical record must SUPPORT the medical necessity for the item. It does not
say that the medical record must exhaustively prove the necessity; but
simply that is must “support” the medical necessity. “The patient’s medical
record is NOT limited to the physician’s office records.it may
include.records from prosthetists, and orthotists” (Chapter 3 “Documentation
in the Patient’s Medical Record). Do not allow Medicare or its contractors
to overlook or dismiss your documentation, the Manual allows for your
records to be admitted as part of the patient’s medical record.
Please contact my website for more additional tips and news concerning
Medicare audits: https://www.facebook.com/RACsupport
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You’re going to have to take it all the way to ALJ. Everything before then
has been denied on my claims. You more than likely will win on ALJ. ALJ
court dates recently have been over a year out and when you get to that
level they recoup the money on future claims even before you have your ALJ
hearing. Good luck and definitely fight it.
Real simple and forward. Ask to see the section in Medicare guidelines where
it states that is not a covered item. Good luck and that should end
everything immediately cause it is not listed as an non-covered code.
Here is some information that might help, just a description that might help
to justify and some references.
Good luck!
L-Code
L5981
Description
All lower extremity prostheses, Flex Walk system or equal.
Justification
Carbon fiber foot allows for smooth roll-over, energy storing, and dynamic
response which is medically necessary to reduce walking effort, to reduce
impact and damage to the joints and limb, to reduce fatigue, to reduce
pressure on the sound side and lower back, to control the ankle in stance
phase, and to improve walking symmetry which will accommodate the patient’s
demanding activities of daily living.
References
Influence of prosthetic foot design on sound limb loading in adults with
unilateral below-knee amputations. CM Powers, et al. Arch Phys Med Rehabil
Vol. 75 No. 7, Jul 1994, p. 825-829.
Biomechanical analysis of the influence of prosthetic feet on below-knee
amputee walking. A. Gitter, et al. Am J Phys Med Rehabil Vol. 70 No. 3,
Jun 1991, p. 142-148.
Mechanical Properties of prosthetic limbs: adapting to the patient. Glenn K.
Klute PhD, et al. JRRD Vol. 38 No. 3, May/Jun 2001, p. 299-307.
AMPRO activity level predictor has helped me on the same code and my pt only
achieved K3 by 1 point. Good Luck!
Can you possibly videotape the patient ambulating at a K3 level? I have
heard that this helps greatly!
Hope it helps!
Did they deny the entire claim or just the foot code? I have a bunch of
appeals pending for this code. Haven’t won one yet. Most are at ALJ level
right now, sitting doing nothing so I am working to have them escalated to
the MAC Review. For my claims, they have denied the entire claim due to
the foot code when the foot code is really the only code that has a K-Level
Classification. So, in my appeals, I specifically state that though we feel
we have provided more than enough information to justify the medical
necessity specifically for the foot, at the least, all of the other codes
should be paid and not held up due to the foot code being questioned.
I also type out a cover letter and pull specific documentation out and
restate it in the cover letter. For example: “On 1/1/12, Dr. So and So
states ‘Mr. Doe is a K3 ambulator. He works in his garden, mows his lawn,
walks his dog, etc”. So, I underline supportive information within the
documentation and then restate it in a cover letter.
Honestly, at this point, if it Prepay audits we have a pretty good success
rate at getting it to pay at the Prepay audit, but if it starts at
Redetermination, we haven’t had one pay yet. It seems as if once its at
Redetermination, you are stuck going all the way through the appeal levels.
Hopefully this helps you a little bit. The most important thing I think is
that if they denied the whole claim instead of paying all the codes except
the foot, I would definitely argue that point. The only money they should
be withholding is the foot, not the entire claim.
