1. High-Tech Prosthetics; Is There a Place For It?
PRESENTED BY:
Aaron Sorensen, MBA, CPO, LPO
O and P Billing Solutions, Inc.

2. Schedule of Topics What are “High Tech Lower Extremity Prosthetics”?
Payer sources
Payer concerns
Documentation approaches
Medicare coverage limitations and concerns

3. High Tech Prosthetics What is considered High Tech? Payers
Experimental
Motor driven
External power source
Computer involvement
Lumped under misc./codes

4. High Tech Prosthetics Why different definitions?
Different Payer sources/different rules & regulations
Work Comp
State regulations
Federal payer sources VA
DOD
Medicare
Commercial payers
Medicare plans
Non-Medicare plans

5. High Tech Prosthetics Component exceptions
Some payers have exceptions vs. commercial traditional payers
Work Comp
Law suit settlements
DOD (Dept of Defense) VA
Self funded plans

6. High Tech Prosthetics Payer Concerns (non- clinical)
Obvious Answer – Money
Control flow of funds?
Policy verbiage?
Not proven technology
Not recognized technology
Payer has defined it as experimental
Experimental procedures and devices non-covered

7. High Tech Prosthetics Payer Concerns (Clinical) Payers vary
#1 reason
Medical necessity
Payers vary
Some have pre- determined internal tests to complete
i.e. – VA, HealthSpring
Vary between payer
Some look at historical documentation
i.e. - Medicare

8. High Tech Prosthetics Payer Concerns (clinical) Pt’s cognitive level
Upper extremity dexterity/strength
Contralateral side concerns
Other contributing issues:
Back issues
Home/environmental barriers

9. High Tech Prosthetics Documentation (CMS)
Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary
A determination of the medical necessity for certain components/additions to the prosthesis is based on the patient's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:
The patient's past history (including prior prosthetic use if applicable); and
The patient's current condition including the status of the residual limb and the nature of other medical problems

10. High Tech Prosthetics Documentation approaches (non-CMS)
1st understand your payer
Do they have a pre- determined test?
If not, what is payer’s policy toward High Tech/High Dollar products?
Video pt. completing test (regardless of payer source)
With old componentry, new componentry and no prosthesis
Pt/PT/MD sign attestation to test

11. High Tech Prosthetics No pre-determined test by payer…
Use industry established and accepted tests
i.e. Amputee mobility predictor
Use your own
Some payers do not like templates
This can be developed for your area of the country; topography/landscape

12. High Tech Prosthetics Documentation approaches (non- CMS)
Understand your patient’s policy verbiage
Are there explicitly written exclusions
Any verbiage regarding microprocessors
Is “experimental” defined?

13. High Tech Prosthetics Understand the Payer procedures
Is there a pre-cert required?
Is pre-determination available?
What is the appeals process?
If work comp, is the attorney’s involvement needed?

14. High Tech Prosthetics Documentation Administering the test
Prosthetist or other healthcare professional?
Appear unbiased if no financial gain attached to outcome for the device PT
scope of practice
Physiatrist
Physician requirement
Can also complete Peer-to-peer appeal requirement
Prosthetist can assist?!

15. High Tech Prosthetics
What are some of these codes?
L5856 ENDOSKELETAL KNEE- SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING AND STANCE PHASE, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
L5857 ENDOSKELETAL KNEE- SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, SWING PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
L5858 ENDOSKELETAL KNEE SHIN SYSTEM, MICROPROCESSOR CONTROL FEATURE, STANCE PHASE ONLY, INCLUDES ELECTRONIC SENSOR(S), ANY TYPE
L5859 ENDOSKELETAL KNEE- SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S)
L5973 ENDOSKELETAL ANKLE FOOT SYSTEM, MICROPROCESSOR CONTROLLED FEATURE, DORSIFLEXION AND/OR PLANTAR FLEXION CONTROL, INCLUDES POWER SOURCE
L5969 ENDOSKELETAL ANKLE- FOOT OR ANKLE SYSTEM, POWER ASSIST, INCLUDES ANY TYPE MOTOR(S)

16. High Tech Prosthetics Medicare regulations/LCDs Foot/ankle systems
L is not covered if there is insufficient information to demonstrate that the item meets the Medicare standard to be considered reasonable and necessary as per PIM (provider Integrity manual) Chapter 13. Claims for L5969 will be denied as not reasonable and necessary.
-and- Guidance/Guidance/Transmittals/ downloads/R24PIM.pdf
Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of foot. This information must be retained in the physician's or prosthetist's files.

17. High Tech Prosthetics CMS LCD limitations
L5859 (ADDITION TO LOWER EXTREMITY PROSTHESIS, ENDOSKELETAL KNEE-SHIN SYSTEM, POWERED AND PROGRAMMABLE FLEXION/EXTENSION ASSIST CONTROL, INCLUDES ANY TYPE MOTOR(S)) is only covered when the beneficiary meets all of the criteria below:
Has a microprocessor (swing and stance phase type (L5856)) controlled (electronic) knee
K3 functional level only
Weight greater than 110 lbs. and less than 275 lbs.
Has a documented comorbity of the spine and/or sound limb affecting hip extension and/or quadriceps function that impairs K-3 level function with the use of a microprocessor-controlled knee alone
Is able to make use of a product that requires daily charging
Is able to understand and respond to error alerts and alarms indicating problems with the function of the unit
If these coverage criteria for the knee component are not met, L5859 will be denied as not reasonable and necessary.

18. THANK YOU
Freedom Innovations thanks you for your continued support and hopes this series of webinars helps you navigate the tumultuous environment of serving MEDICARE PATIENTS.
Please provide feedback to your Freedom sales representative of future topics to cover and if you find these webinars helpful.
Next webinar: Nov. 7, 2014
Topic: How to Build a Successful O & P Practice
Aaron Sorensen, CPO, LPO, President OPBS Ph
Rob Cripe, VP Global Marketing Ph