Referring Medicare Patients for Prosthetic Care

When referring Medicare patients for prosthetic care, a smooth transition can help reduce the risk of inconvenience, delays, and unnecessary costs. Ensuring your documentation meets Medicare requirements is an essential part of the process and will help make things easier for everyone involved—most importantly, your patients.

Five Tenets of Prosthetic Documentation

Here are the five pieces of information needed to ensure your prosthetic notes are corroborated in the medical record.

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 overview of the medical history is required (history and physical)

Medicare Documentation Requirements for Prosthetic Limbs^1-3

Documentation should address mobility and be patient specific.

1. For patients with a recent amputation:
   What would the overall health benefit be from using a prosthesis?
2. For patients experienced with the use of a prosthesis:
   What is wrong with the current prosthesis, and how does it limit daily function?
3. For every patient with an amputation: 
   What health problems are present that may affect the ability to walk with a prosthesis, and/or what (physical or mental) health benefits are expected from the use of a prosthesis?

1. Lower limb prosthetic workgroup consensus document (Sept. 2017) Center for Medicare and Medicaid Services Health Technology Assessment. 
2. CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapters 3 and 5.
3. Centers for Medicare & Medicaid Services. LCD for Lower Limb Prostheses.