Bowling for Denials

I wanted to pass along a very interesting post from Ossur’s R&R blog by David McGill on Medicare contract auditors trolling for information in an attempt to rewrite requirements for lower limb prostheses to their liking. If you are not already signed up to receive updates from the R&R blog, it is a thought provoking site that you should know about!

By: David McGill, Vice President, Reimbursement & Compliance

Over the last 30 days, we have heard from multiple customers in Region D that they have received a new “form letter” from HDI, their Recovery Auditor. In this document, HDI claims that the prosthetist’s medical record contains inadequate proof that the patient qualifies for the K3 functional level. More specifically, the letters state that the patient doesn’t participate in the kinds of activities typically engaged in to require the K3 component fit by the prosthetist. 

The letter then lists the kinds of alleged “K3” activities it expects to see:

  • bowling; hiking; dancing; running; hunting; climbing; and playing baseball.

Analysis

The Local Coverage Determination for Lower Limb Prostheses defines the K levels. A K3 patient 

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.

Nowhere in the LCD’s definition of “K3” or anywhere else in that document or the accompanying policy article do the MACs list even a single activity representative of a K3 ambulator. To suddenly list a group of sports that should appear in the prosthetist’s records strikes us as problematic at best, and fundamentally unfair at worst. Based on our historical experience interacting directly with amputees, a huge percentage of legitimate K3 ambulators participate in none of these activities. Does that mean they fail to satisfy the LCD’s definition of a K3 user? No, it just reflects the reality that many amputees (and many non-amputees, for that matter) live active lives that don’t include hurling a bowling ball down a lane, going for a jaunt on the Appalachian Trail, doing the Electric Slide, finishing a 5K race, shooting deer, ascending a rock wall, or playing shortstop.

Second, and just as troubling, if we’re going to play the “Let’s List Activities Describing K Levels Game,” HDI’s list appears to more accurately describe K4-level amputees than K3. Look at the definition of a K4 walker:

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.

Now consider each of the activities listed by HDI. Do bowling, hiking, dancing, running, hunting, climbing and playing baseball all require prosthetic ambulation “that exceeds basic ambulation skills”? Check. Do they all exhibit high impact, stress, or energy levels? Check. Are they typical of the prosthetic demands of a child, active adult, or athlete? Check. 

So to summarize: (1) HDI has effectively created a new standard for K3 amputees, and (2) it has compounded the issue by selecting activities that fail to describe that functional level. 

What does this mean for you?

If you receive a letter from your RA that mirrors or is similar to the one described above, we do not recommend playing the “List Activities Describing K Levels Game.” If you do this, you implicitly endorse the RA’s new approach to K-level determination, giving it authority it doesn’t actually possess.

Instead, focus first and foremost on the LCD. The LCD for Lower Limb Prostheses sets forth Medicare’s coverage requirements for a prosthetic claim. You need to clearly and forcefully emphasize in any counterargument that the LCD doesn’t list any of the activities in the letter, nor do those activities necessarily describe a K3 ambulator. Then make sure your notes contain proof that your patient (a) can or has the potential to walk with variable cadence, (b) has the ability to traverse most environmental barriers, and (c) has vocational, therapeutic, or exercise activity demanding prosthetic utilization beyond simple locomotion. 

The RA’s are bowling for denials. Don’t play their game!


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