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For Physicians
When Referring Your Patient to a Prosthetist
Medicare guidlines for physicians
A. Physical Exam
(relevant to functional deficits)
• Weight, height, weight loss/gain
• Cardiopulmonary examination
• Musculoskeletal examination (arm and leg strength; range of motion)
• Neurological examination; gait, balance and coordination
B. History of amputation
• Diagnosis/Reason for amputation(s)
• Date of amputation(s)
• Side of amputation(s)
• Clinical course
• Therapeutic interventions and results
• Prognosis
C. Functional Deficits
Symptoms limiting ambulation/dexterity
• Medical history relevant to deficit(s)
• Activities of daily living (ADL) and how impacted by deficit(s)
• Diagnosis causing these symptoms
• Other comorbidities
• Other ambulatory assistance currently used (wheelchair, walker, cane, caregiver, etc. with/without prosthesis)
D. Functional level
Describe patient's ADL on a typical day in terms of functional capability (see section E for lower extremity)
• Patient's functional capabilities prior to amputation
• Patient's current functional capability
• Patient's expected functional potential with use of the new prosthesis and explanation for the difference (if any)
E. Motivation to use prosthesis
Describe patient's desire to use the new prosthesis or to ambulate (if lower extremity)
F. Describe the condition of the residual limb
• Is there skin irritation, breakdown, or infection?
• Are limb volume changes occuring?
• Is there swelling, weight fluctuations, or muscle change?
• Is the limb fully healed?
G. Condition/status of current prosthesis/component
Why is a replacement needed?
• If the current prosthesis/component is worn or broken, describe which component needs to be evaluated for repair/replacement
• If the patient's condition has changed, describe why the current prosthesis/component is no longer appropriate
Examples: skin irritation, limb volume change, weight gain/loss, decreased stability
If the patient's functional level has changed, describe why the current prosthesis/component will not allow the patient to achieve the desired function (see section D for descriptions)
H. Patient's past experience with prosthesis
• Which other prosthesis/components have been tried in the past?
• Describe any problems patient expienced (e.g. barriers to ambulation, balance, stumble, inability to perform activities, problems with back or sound side limb)
I. Recommendation for new prosthesis/component(s) based on your functional level evaluation-Section D.
This should be part of your treatment plan. You do not need to specify the brand of device.
Medicare
Medicare's Functional Levels
(for lower extremity)
Level 1 - Household Ambulator:
Has the ability or potential to use prosthesis for transfers/
ambulation on level surfaces at fixed cadence.
Level 2 - Limited Community Ambulator:
Has the ability or potential for ambulation and to traverse low level environmental barriers such as curbs, stairs, or even surfaces.
Level 3 - Unlimited Ambulator:
Has the ability or potential for ambulation with variable cadence, to traverse most environmental barriers, and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
Level 4 - Child, Ative Adult, or Athlete
Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels.
New Medicare Requirements!
In order to be in compliance with Medicare and receive reimbursement, the information in this needs to be documented in your medical records, and provided to he prosthetist as part of the referral process. This will ensure that your patient recieves the prosthetic limb/component as quickly as possible. If it is not within the scope of your practice to provide this information, please assist your patient to locate a physician to document and order the prosthesis.
Clarification issued by Medicare, August 2011:
Reimbursement for the prosthesis/
prosthetic component is based solely on the information in the physician's contemporaneous medical records.*
*References
DME MAC letter, "Dear Physician - Documentation of Artificial Limbs," issued August 11, 2011
CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapters 4 and 5
Centers for Medicare & Medicaid services. LCD for Lower Limb Prostheses. Effective January 2012; Article for Lower Limb Prosthesis. policy Article. Effective August 2011
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