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

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

High Tech Prosthetics What is considered High Tech? Payers Experimental Motor driven External power source Computer involvement Lumped under ..99 misc./codes

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

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

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

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

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

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

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

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

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?

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?

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?!

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)

High Tech Prosthetics Medicare regulations/LCDs Foot/ankle systems L5969 - 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. https://www.cms.gov/Regulations -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.

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.

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 asorensen@rhs-tn.com Ph. 877-907-4180 Rob Cripe, VP Global Marketing rcripe@freedom-innovations.com Ph. 949-544-7916