Documentation for K level prosthetics

INDIANAPOLIS, Ind., March 14, 2013—National Government Services, the Jurisdiction B Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has received several inquiries in regards to what documentation must appear in the medical record to support the K level for prosthetics. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to:

• The beneficiary’s past history (including prior prosthetic use if applicable); and
• The beneficiary’s current condition including the status of the residual limb and the nature of other medical problems; and
• The beneficiary’s desire to ambulate.

This information must be documented by the treating physician and the prosthetist.

The medical record should reflect that a comprehensive medical assessment has occurred. The medical record should include, but is not limited to, past history, current functional capabilities and the beneficiary’s expected functional potential, including an explanation for the difference, if that is the case. The medical record should establish the severity of the beneficiary’s condition and the immediate and long term need for the prosthetic and the therapeutic benefits the beneficiary is expected to realize from its use. An entry in the medical record of therapeutic effectiveness or benefit based on speculation or theory alone cannot be accepted. When restoration of function is cited as a reason for use of the prosthetic, the exact nature of the deformity or medical problem should be clear from the medical evidence submitted. Also, the manner in which the prosthetic will restore or improve the bodily function should be explained by the treating physician. The K-level selected must be consistent with the overall health status of the beneficiary. Coverage is extended only if there is sufficient clinical documentation of functional need for the technologic or design feature of a given type of prosthetic.

Note: Suppliers are reminded per the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-08, Program Integrity Manual, Chapter 5, (Section 5.7-5.9, supplier-produced records, even if signed by the ordering physician, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.