I have often heard this term used to describe orthotic and prosthetic (O&P) services, usually by payer sources that simply focus on the cost of services. Little effort is made to understand the professional protocols governing the component selection process or how this process matches patient's abilities, needs, and environmental demands with appropriate technology in an effort to maximize function. Historically, Medicare has had no internal qualifying standards that relate which components or procedures would be appropriate for which levels of amputee, until recently. With the introduction of the K-modifiers, we now have functional level determinants to help organize components and the amputee's access to them. They range from K0-K4.
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.
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.
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.
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.
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.
A person's access specifically to the technology surrounding the knees, feet, and ankles is governed by the clinical assessment of his or her functional level potential - typically arrived at by your prosthetist and physician. It may also include your therapist if one is involved. While these protections and guidelines are in place to protect Medicare from inappropriately using technology for a K3 level on a patient that is a K1 level, for example, we have found that the classifications are well within clinically acceptable rationale and helps to ensure that your components and their costs are appropriate to support your potential functional level. In addition, none of these levels are locked in stone. If a person can improve to a higher functional level than was originally anticipated, they can be reclassified with access to the next level of components to support that new functional level.
Who can Provide Service?
The Medicare system, while it has certain procedural requirements to receive a Medicare number for billing purposes, is silent on the subject of professional credentialing. As such, anyone, trained or untrained, is given the opportunity to provide these services and be reimbursed by Medicare. This continues to be the case, even after years of objection and recommendations by the profession to establish minimum levels of competency to provide these services as a requirement to accessing the L-Code system as a means to bill Medicare for services. The argument on behalf of Medicare has always been that this request is too "self-serving" coming from the organized profession and would not be entertained as this would be tantamount to giving the fox the keys to the hen house. While this is a quaint analogy, history has proven that Medicare's unwillingness to adopt this philosophy has made them as responsible for the fraud and abuse as the people perpetuating the fraud and abuse. While no profession is without its bad apples, the evidence available to the organized field suggests that the vast amount of fraud and abuse that has been identified in O&P has come from outside the organized professional field and is directly related to the free access to the L-Code system of billing to Medicare by non-credentialed or unqualified providers.
How do I Find Qualified Services?
While certification and credentialing in and of themselves are no guaranty of a successful outcome, they do attest to minimal levels of competency in one's chosen profession, whether it is a neurosurgeon or a prosthetist. The oldest and most widely accepted credential for the profession is that of the American Board for Certification (ABC), which has conducted the competency exam process for prosthetics and orthotics since 1948. All practitioners must then meet mandatory continuing education standards over a 5-year period to remain certified by ABC. It has expanded the individual certification to include an ABC Facility Accreditation, which establishes high standards for a larger spectrum of programs affecting patient care beyond individual certification. Standards in the areas of ethical billing practices, quality improvement, patient satisfaction surveys, problem resolution pathways, patient record keeping, physician communication standards, and professional guidelines governing the physical facility and conduct of the entire staff serving your needs are addressed in the Facilities Accreditation Credential.
Other qualifications include the Board for Orthotic Certification (BOC), and state licensing or state certification, which is present in some states. After verifying credentialing, the important elements center on finding a person whom you can relate to and work with. It is very helpful if you can establish chemistry between yourself and your prosthetist. Personality and competency will play a key role in meeting your prosthetic needs for the rest of your life. Unlike all other medical professionals that you contact, the relationship that you have with your prosthetist is usually a lifelong relationship. Exercise care in this process and it will yield dividends.
I'm Only one Person. What can I do?
I relate this information to you because it is rapidly becoming necessary for you, as end users of these services, to take on the responsibility of becoming more highly educated and involved. This is needed not only to understand the technology and procedures as they improve the potential quality of your life, but also in those factors affecting the availability and your access to advancing O&P services. It is becoming increasingly necessary for you to find ways to have your voice heard within the current HCFA system, as it exists today to ensure coverage for your O&P needs. In becoming more educated, your active involvement will become the most effective method of addressing needed changes through your elected officials. The organized O&P profession is extremely small in the eyes of HCFA. The profession will never be as effective as we need to be to ensure quality and access to the care that you receive today and in the future.
Understanding the importance of your role in affecting public policy and becoming more active on both a state and national level will not only be welcomed but required if we are to have any chance of maintaining the quality of services, professionals, and your access to them in the future.
