08.04.2011 · BELOW KNEE (TRANS-TIBIAL) PROSTHESIS

Short- term rental and rent- to- purchase. The rental of DME may be approved when it is determined to be more cost-effective than purchase. The approved rental period under one prior authorization number shall not exceed six months, unless specified elsewhere in Chapter 5101:3-10 of the Administrative Code. Payment for short- term rental will be made at ten per cent per month of the maximum amount allowable . Providers should use the modifier RR when billing short-term rental. If a prior authorization request is received for a second rental period, the department will make a determination on whether to purchase the item. Upon a decision to purchase, all prior rental payments will apply toward the purchase price and the provider will receive one final payment for the remainder of the item's maximum allowable amount as specified in appendix DD to rule 5101:3-1-60 of the Administrative Code. The provider will notify the consumer when an item has been purchased on their behalf. The reimbursement for items purchased within ninety days of the end of a rental period, inclusive of all rental payments and the remaining purchase price, cannot exceed the medicaid maximum amount. Prior authorization is required prior to reimbursment for those DME items designated as R/P in appendix A to rule 5101:3-10-03 of the Administrative Code. For items authorized for monthly rental on a monthly basis, payment will be made through the end of the month in which: the consumer becomes ineligible,; the item is no longer medically necessary; or, the maximum amount allowable is reached. For items authorized for rental on a daily basis, the items are billiable only those days when the consumer is eligible and the item is medically necessary. Medicare-covered services provided to residents of long-term care facilities who are dually eligible for medicare and medicaid must be billed directly to medicare. Following payment by medicare, medicaid payment will be made directly to the provider. Reimbursement for a back-up ventilator may be allowed upon provision of the documentation required in rule 5101:3-10-22 of the Administrative Code. With the exception of nonmolded helmets and splints, all covered orthotic and prosthetic devices listed in appendix A to rule 5101:3-10-20 of the Administrative Code may be submitted for reimbursement when provided to eligible residents of nursing facilities. RT (right side) and LT (left side) modifiersUse of either the RT or LT modifiers is required when billing for the codes listed at . For items having the same billing code and dispensed bilaterally on the same date of service for the same consumer, both the RT and the LT modifier must be used. Effective: 07/01/2013
R.C. review dates: 01/01/2015
Promulgated Under:
Statutory Authority: , Sect. 309.30.75 of Am. Sub. H.B. 1 of 128th GA
Rule Amplifies: , , , Section 309.30 75 of Am. Sub. H.B. 1 of 128th GA
Prior Effective Dates: 4/7/77, 12/21/77, 12/30/77, 1/1/80, 3/1/84, 10/1/88, 5/1/90, 6/20/90 (Emer), 9/5/90, 2/17/91, 9/1/98, 7/1/04, 7/1/06 , 1/1/10

The PTB prosthesis is usually suitable for 90% of amputees with below the knee amputations.

Providers are required to maintain proof of delivery documentation for durable medical equipment (DME), medical supplies and orthotics and prosthetics dispensed to consumers. . Accepted criteria for proof of delivery documentation are as follows: Providers, their employees, or anyone else having a financial interest in the delivery of DME, medical supplies or orthotic and prosthetic items are prohibited from signing and accepting an item on behalf of a consumer; and Any person accepting a delivery of DME, medical supplies or orthotic and prosthetic items on behalf of a consumer will note on the delivery slip their relationship to the consumer. . The signature of the person accepting the delivery should be legible. If the signature is not legible, the provider/ shipping service will note the name of the person accepting the delivery on the delivery slip; or If the provider utilizes a shipping service or mail order, an example of proof of delivery would include the service's tracking slip, and the supplier's own invoice. If possible, the supplier's records will also include the delivery service's package identification number. The tracking slip will reference each individual package, the delivery address, the corresponding package identification number , and the date delivered. The provider shall use the shipping date as the date of service on the claim. Providers may also utilize a return postage-paid delivery invoice from the consumer or consumer's designee as a form of proof of delivery. The descriptive information concerning the DME, medical supplies or orthotic and prosthetic item (i.e., the consumer's name, the quantity, detailed description, brand name, and serial number) as well as the required signatures from either the consumer or the consumer's designee must be included on this invoice as well; and For residents of a long term care facility , providers will obtain legible copies of the necessary documentation from the nursing facility to document proof of delivery or usage by the consumer (e.g., nurse's notes).


For most patients with a below-the-knee amputation the …

If the provider utilizes a shipping service or mail order, an example of proof of delivery would include the service's tracking slip, and the supplier's own invoice. If possible, the supplier's records will also include the delivery service's package identification number. The tracking slip will reference each individual package, the delivery address, the corresponding package identification number , and the date delivered. The provider shall use the shipping date as the date of service on the claim. Providers may also utilize a return postage-paid delivery invoice from the consumer or consumer's designee as a form of proof of delivery. The descriptive information concerning the DME, medical supplies or orthotic and prosthetic item (i.e., the consumer's name, the quantity, detailed description, brand name, and serial number) as well as the required signatures from either the consumer or the consumer's designee must be included on this invoice as well; and


Below Knee Prosthesis PTB Strap, Elastic with Fork Strap, Hook …

Orthopedic shoes are denied as non-covered if the shoe is put on over a partial foot prosthesis or other lower extremity prosthesis that is attached to the residual limb.

Suspension of the below-knee prosthesis: An overview

Definitions and explanations."Basic equipment package" is the following standard set of parts and accessories that come with a wheelchair at the time of purchase:A sling or solid seat with back, a captain's chair, or a stadium-style seat;Standard casters or wheels with tires;Standard armrests;Standard front rigging (e.g., non-elevating legrests with footrests, a footplate);Wheel locks or brakes;With a power mobility device, motors;With a power mobility device, a non-expandable controller; With a power mobility device, a battery charger;With a power wheelchair, a standard proportional joystick; andWith a power-operated vehicle, batteries."Complex rehabilitation technology (CRT)" is a categorization of wheelchair equipment items that require individual evaluation, fitting, configuration, adjustment, or programming to meet the specific medical and functional needs of the user, as well as services related to those products. CRT includes, for example, customized seating systems, adaptive positioning devices, and alternative drive systems (directional interfaces other than a standard joystick)."Custom wheelchair" is a wheelchair that has a customized seating system. A custom wheelchair, therefore, cannot be easily used or adapted for use by another individual."Customized seating system" is a wheelchair seat, wheelchair back, or combination of wheelchair seat and back that has been tailored specifically to the particular body shape and positioning needs of an individual user. Customization may be achieved by means of molding, contouring, carving, or other forms of fabrication or by the integration of prefabricated components into the wheelchair frame. Items such as seat cushions and other removable positioning aids do not by themselves constitute a customized seating system."DMEPOS Fee Schedule" is a list of payment amounts for durable medical equipment, prostheses, orthoses, and supplies published by the centers for medicare and medicaid services (CMS); it is available at . The January 2015 revision is the basis for the medicaid payment amounts described in paragraph (E) of this rule. "Individualized seating system" is a wheelchair seat, wheelchair back, or combination of wheelchair seat and back that has been tailored to the body shape and positioning needs of an individual user by means of installing and configuring prefabricated cushions or other removable positioning aids."Medical necessity" is defined in rule of the Administrative Code.Wheelchairs and wheelchair parts and accessories must meet additional criteria in order to be considered medically necessary:Wheelchairs and wheelchair parts and accessories are generally not necessary nor even useful in the absence of illness, injury, impairment, disability, or other condition that limits ambulation. A wheelchair must therefore provide mobility to an individual for whom ambulation is not possible, takes inordinate physical effort, or causes considerable physical discomfort.A wheelchair must also be suited to the purposes and daily routines of the individual using it.A manual wheelchair must provide a level of needed functionality that cannot be achieved with an assistive device such as a cane, a crutch or crutches, or a walker.A power mobility device (PMD) must provide a level of needed functionality that cannot be achieved with a manual wheelchair.A PMD must be functional in the environment in which it is used. The individual (or someone assisting the individual) must have the ability to take proper care of the PMD, the individual's place of residence must be accessible and have adequate electrical service, transportation of the PMD must be available as necessary, and there must be sufficient protection for the PMD from the elements. The place of residence is considered to be accessible only if the individual will be able to use the PMD without assistance to enter and leave the residence and to move easily about the main living space (which is used for purposes such as food preparation, eating, sleeping, personal hygiene, and relaxation).A customized seating system must enable an individual to sit (or recline, as appropriate) for long periods of time, provide postural support to permit functional activities, or reduce pressure on the body to a degree that cannot be achieved with items such as a standard wheelchair seat, an individualized seating system (e.g., a prefabricated seat cushion or other removable positioning aid or combination of positioning aids), or a spinal orthotic device."Need verification" is a process, similar to prior authorization, by which the department determines whether to make payment for the repair of a wheelchair part or accessory that exceeds the established frequency guideline. One purpose of need verification is to enable the department to consider whether the purchase of a new piece of equipment might be more cost-effective than continued repair."Power mobility device (PMD)" is a collective term for a power wheelchair or a power-operated vehicle (POV, commonly referred to as a "scooter"). Each PMD is classified on the basis of performance into one of eight groups developed under the auspices of CMS:Group one power-operated vehicles;Group two power-operated vehicles;Group one power wheelchairs;Group two power wheelchairs;Group three power wheelchairs;Group four power wheelchairs;Group five power wheelchairs; andPower mobility devices not otherwise classified."Routine maintenance" of a wheelchair is any upkeep that is necessary to maintain optimum functioning of the equipment and that does not require a skilled or trained technician to perform."Wheelchair" is a collective term for a manual wheelchair or a power mobility device.