Medicare Documentation Requirements*
Patient’s amputation level and any co-morbidities related to ambulatory status.
Desire To Function With A Prosthesis:
Confirmation the patient has the desire to function with a prosthesis.
Ability To Function With A Prosthesis:
Confirmation the patient has or will have the ability to function with a prosthesis.
Current and Expected Functional Level:
Patient’s current and expected Medicare functional level as one of the following:
K4 HIGH ACTIVE ATHLETIC AMBULATOR:
Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills: high impact, stress, or energy levels.
K3 COMMUNITY 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.
K2 LIMITED COMMUNITY AMBULATOR:
Has the ability or potential for ambulation and to traverse low level environmental barriers such as curbs, stairs or uneven surfaces.
K1 HOUSEHOLD AMBULATOR:
Has the ability or potential to use prosthesis for transfers /ambulation on level surfaces at fixed cadence.
Multi-Discipline Corroboration: Provide specifics to validate your opinion as to why your patient meets the standard of the expected functional level you have selected.
EXAMPLE OF A K4 VALIDATION STATEMENT
The patient is an active athletic ambulator participating in activities such as skiing, high impact sports and long distance running.
EXAMPLE OF A K3 VALIDATION STATEMENT
The patient has the potential to be a community ambulator and walks at varying speeds in the community on a regular basis for activities of living such as shopping, and attending community services and events. Patient requires the ability to change speeds while walking in public places and also will be required to walk on uneven surfaces such as grass, gravel, curbs, ramps and stairs.
EXAMPLE OF A K2 VALIDATION STATEMENT
This patient is a limited community ambulator living in a home that has entrance stairs as well as stairs, steps and floor rugs causing uneven surfaces inside the home.
EXAMPLE OF A K1 VALIDATION STATEMENT
This patient is a household ambulator who resides in an assisted living home and walks indoors with the aid of a walker.
Clarification issued by Medicare
Reimbursement for the prosthesis/prosthetic component is primarily based on information in the physician’s contemporaneous medical records.*
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 2016.