Referring Medicare Patients for Prosthetic Care

Improving Your Patient's Satisfaction


When you refer Medicare patients for prosthetic care, a smooth transition can improve your patient’s experience. In an effort to help reduce the risk of inconvenience, delays and unnecessary cost to your patients, we have included an outline of the five pieces of information needed to ensure the prosthetic notes are corroborated in the medical record.


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Medicare Documentation Requirements for Prosthetic Limbs*

Documentation Principles:

Documentation should address mobility and be patient specific. 

For patients with a recent amputation:
What would the overall health benefit be from using a prosthesis? 

For patients experienced with use of a prosthesis:
What is wrong with the current prosthesis and how does it limit daily function?

For every patient with an amputation: 
What health problems are present that may affect ability to walk with a prosthesis and/or what (physical or mental) health benefits are expected from use of a prosthesis? 

Current Five Tenets

  1. Patient has expressed a desire to ambulate with a prosthesis 

  2. Current functional level 

  3. Expected functional level
    NOTE: If current and expected K-levels differ, the reason for the difference must be explained. 

  4. Physician agreement of the proposed prosthetic services 

  5. Are there any comorbid conditions that will affect ambulation or the patient’s ability to use the prosthesis? Explain. 
    NOTE: Generally an overvi
    ew of the medical history is required (history and physical)


*REFERENCES:

Lower limb prosthetic workgroup consensus document (Sept. 2017) Center for Medicare and Medicaid Services Health Technology Assessment 

CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapters 3 and 5.

Centers for Medicare & Medicaid Services. LCD for Lower Limb Prostheses.