In July of 2015 the Centers for Medicare & Medicaid Services issued a new proposed Local Coverage Determination (LCD DL33787) that would severely limit or eliminate payment for lower extremity prostheses for geriatric patients. As most of us know, after discussion and open-door forums, proposed rules become law. When enacted, this rule will turn back the clock to 1980, and most (if not all) prostheses will become unavailable to our amputee patients. So far, this LCD is flying under the radar, and it appears CMS doesn’t want to publicize what will negatively impact their clients.
The LCD has stated requirements for three types of prostheses, all transitioned and paid within 90 days and only when a set of unattainable goals are met.
The OIG has stated that the Immediate Post-Op prosthesis is available only when “…the beneficiary is motivated to ambulate using the prosthesis…” and “…if the beneficiary is unwilling or unable to use the prosthesis, the claim will be denied…”
Really? How is the motivation of the amputee determined? Whose crystal ball will be used to determine whether the client will be willing or able to use the prosthesis? At what point will the provider’s reimbursement be denied because the prognosis was favorable, but the client had co-morbidities that prevented the continuous use of the prosthesis?
The Preparatory Prosthesis will only be covered after the incision is healed and the patient is “…motivated to ambulate using the prosthesis…”
Will Medicare reimburse a psychiatric evaluation to determine the client’s “motivation”? Who makes that determination, and will the claim be denied because the documentation reviewer has had a bad day and doesn’t think the client he sees on paper is motivated?
The Definitive Prosthesis is provided only AFTER the rehabilitation program has been completed and the client is “motivated” to ambulate. It also requires that the client meet functional K codes specifications that include not using a cane or walker, and yet have a “normal” gait. It also requires that the geriatric patient “….don and doff the prosthesis without assistance….transfer independently with/without the prosthesis…attain a Tinetti score of >24…” The Tinetti score appears to be an arbitrary choice. According to the Tinetti, anyone who uses any assistive device, uses the arms of the chair to rise or sit, and has discrepancies in step length with a prosthesis, has already failed attaining a score of 24.
Under this proposed rule, our geriatric patients will no longer qualify for lower extremity prostheses. If the client has mild dementia and requires the assistance of family to don/doff the prosthesis, it will be denied. If the client has RA of the hands and needs assistance, the prosthesis will be denied. If the client cannot gain “…the appearance of a natural gait…[as defined by whom?]” the prosthesis will be denied.
If the beneficiary does not meet all these requirements within 90 days of getting the immediate prosthesis, Medicare will come back to the prosthetic provider and take back funds provided for the prosthesis.
Our suppliers will not be willing to risk the expense and our amputee clients will no longer get the function-saving equipment needed to preserve their quality of life. This will create a new population of geriatrics who will need more care, more SNF time and are less likely to return home at a functional level. There are many changes that negatively impact the care of our geriatric clientele; this may be the straw that breaks the camel’s back and saves money in the short term by deferring the cost to long-term care.
Call your congressperson. Write letters. Get your clients and their families involved. This law will deteriorate the outcomes and future for our clients, patients, and their families.
Jean Wendland Porter, PT, CCI, is the Regional Director of Therapy Operations atDiversified Health Partners in Ohio.