Functional Levels Determinants for Medicare Coverage
As the patient is progressing toward a determined (i.e., final) prosthesis, there must be documentation of a patient's functional status and ability to benefit from progressively more complex (and expensive) components. "K- Modifiers" are descriptions referenced by Medicare to determine if a patient is eligible for a recommended prosthesis
KO: This patient does not have the ability or potential to ambulate or transfer safely with or without assistance and a prosthesis does not enhance their quality of life or mobility.
Eligible components: SACH or single-axis foot, manually locked, single-axis, polycentric, or weight-activated knee, any suspension or liner, all socket designs
K1: This patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence - a typical limited or unlimited household ambulator.
Eligible components: All of Level 1, also flexible keel or multiaxial feet, rotator and torque absorber
K2: This patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs, or uneven surfaces - a typical community ambulator.
Eligible components: All of Level 1, also flexible keel or multiaxial feet, rotator and torque absorber
K3: The patient has the ability or potential for ambulation with variable cadence - a typical community ambulator with the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic use beyond simple locomotion.
Eligible components: All of Level 1 and Level 2, dynamic response feet, hydraulic/pneumatic knees, dynamic or shock-absorbing pylons. All components allowed.
K4: The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels - typical of the prosthetic demands of the child, active adult, or athlete.
Eligible components: All of Level 1-3, all existing components
Video reflection and assignment preparation: Can you attribute a K level to the persons in the linked videos based on what you have observed functionally?
Physical therapy is often asked to provide summary reports and other impairment and function-based evidence to support a case for determining coverage for a final prosthesis.
Information About Prosthetic Components
Therapists and CPOs can use the Activities of Daily Living Evaluation to provide evidence and support for medical necessity of specific prosthetic components
For additional resources for optimizing reimbursement, visit https://shop.ottobock.us/media/pdf/LLPAuditSurvivalKit.pdf