Most, if not all of you are aware of the proper Local Coverage Determination classifications for lower limb prosthesis, but I wanted to pass the most up-to-date information along as the most recent review from the Office of Inspector General (OIG) that specifically lists these determinations relating to improper payments and payment recoupment. The OIG report focused on the following issues related to recouping payment:
– Billing duplicate units of service
– Billing for combinations of prostheses that were not allowed
– Lack of the ordering physician evaluation
– Lack of amputation in the patient’s claim history
– Lack of required modifiers to reflect patient functional levels
Beneficiaries is classified into one of five potential functional levels based on the reasonable expectations of the supplier and the referring physician. The supplier uses a modifier on the claim to indicate the beneficiary’s potential functional level (K0 to K4). Below are the most up-to-date LCD criteria for K levels:
- K1 – Lower extremity prosthesis functional Level 1 – has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulatory
- K2 – Lower extremity prosthesis functional Level 2 – has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs, or uneven surfaces. Typical of the limited community ambulator
- K3 – Lower extremity prosthesis functional Level 3 – has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion
- K4 – Lower extremity prosthesis functional Level 4 – has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete
A supplier must submit the RT or LT modifier for the applicable HCPCS for the prostheses to be considered for payment. Additionally, if the patient was not seen by a physician or the prosthesis was not ordered by a physician, suppliers may submit their claim with modifier EY to indicate “No physician or other licensed health care provider order for this item or service”.
More information on the LCD’s can be found here.