Volume 23, Issue 5 September/October 2013 | Download PDF
An interview with Interim President & CEO Sue Stout about the importance of amputees knowing their K-levels
inMotion | What is a “K-level” and why is it important?
Sue | K-levels are a rating system used by Medicare to indicate a person’s rehabilitation potential. The system is a rating from 0 through 4 and it indicates a person’s potential to use a prosthetic device if they had a device that worked well for them and they completed rehabilitation to use the device properly. Your K-level designation is important because it is the driving factor in the decision on what prosthetic device to provide to you and the payment for that prosthetic device.
Simply stated, payment by Medicare (and many insurers as well) is guided by the person’s K-level designation.
inMotion | Why does it matter to Medicare what my rehabilitation potential is?
Sue | Medicare wants to ensure that when they pay for someone’s prosthesis, that person will likely be able to use the device. They do not want to pay for and expensive device only to have it sit in the closet unused because it is unrealistic for the person to be up and about. On the other hand, they also want to be sure that if the person has the potential for walking about in the community and getting back into sports, etc., that they receive a device that will allow that to happen. The prosthetic device should match the person’s need and potential.
inMotion | Tell us a little more about K-levels.
Sue | The current approach for classifying amputee activity levels is determined using the Medicare Functional Classification Level (MFCL), also known as K-levels. K-levels are used by the Centers for Medicare & Medicaid Services (CMS) to ensure uniformity in determining which prosthetic devices are medically necessary for each patient. For example, if your physician feels you have the potential to be able to walk around the house, but you will not have the strength or ability to walk on uneven surfaces or to climb curbs and stairs, you would be rated as a household ambulator (walker), ability level K1.
inMotion | How many K-levels are there, and what are the definitions?
Sue | K-levels run 0-4 and Medicare defines them as follows:
The 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. This level does not warrant a prescription for a prosthesis.
The patient has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. This is typical of a household ambulator or a person who only walks about in their own home.
The patient has the ability or potential for ambulation with the ability to traverse low-level environmental barriers such as curbs, stairs or uneven surfaces. This is typical of the limited community ambulator.
The patient has the ability or potential for ambulation with variable cadence. A person at level 3 is typically a community ambulator who also has the ability to traverse most environmental barriers and may have vocational, therapeutic or exercise activity that demands prosthetic use beyond simple locomotion.
The patient has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress or energy levels. This is typical of the prosthetic demands of the child, active adult or athlete.
inMotion | How are different prosthetic devices selected for each amputee patient, and how is insurance coverage determined?
Sue | Let’s take Medicare as our example because many private insurance companies pattern their practices on what Medicare does. In Medicare, the Durable Medical Equipment Medical Administrative Contractors (DME MAC) have jurisdiction for processing claims from prosthetists for artificial limbs. If Medicare has questions about a claim, the Medicare contractor may request medical records to demonstrate that the prosthetic arm or leg was reasonable and necessary – or what is called “medically necessary.” Since the prosthetist is a supplier, the prosthetist’s records must be corroborated by the information in your patient’s medical record. It is the treating physician’s records, not the prosthetist’s, which are used to justify payment.
inMotion | How does the physician make a decision about what is medically necessary for me?
Sue | This is important because your functional capabilities are crucial to establishing the medical necessity for a prosthesis. Many prosthetic components are restricted to specific functional levels, so it is critical that your doctor thoroughly documents your functional capabilities, both before and after amputation. Your doctor should assess your physical and cognitive capabilities. This assessment typically includes:
- History of your present condition(s) and past medical history relevant to functional deficits
- Symptoms limiting ambulation or dexterity
- Diagnoses causing these symptoms
- Other co-morbidities relating to ambulatory problems or impacting your use of a new prosthesis
- What ambulatory assistance (cane, walker, wheelchair, caregiver) you currently use (either in addition to the prosthesis or before amputation)
- Description of daily living activities and how they are impacted by deficit(s)
- Physical examination relevant to functional deficits
- Weight and height, including any recent weight loss/gain
- Cardiopulmonary examination
- Musculoskeletal examination – Arm and leg strength and range of motion
- Neurological examination – Gait – Balance and coordination.
You should be provided with a prescription for prosthetic components that are appropriate for your activity level. Components that are designed for higher activity levels would not be covered under the Medicare policy. Your physician determines your functional ability level. If your functional ability increases over time, your rating can be changed to a higher level.
inMotion | This is all very complex. What is the Amputee Coalition doing to help educate amputees about medical necessity so they can be sure they are getting the right level of prosthetic device?
Sue | An educated patient is better able to ensure he or she is getting the most appropriate prosthesis – and education is a core mission tenet for the Amputee Coalition. Working with our Scientific & Medical Advisory Committee, we are rolling out our “Know Your K-Level” campaign this fall. This campaign will provide information and tools for amputees to use with their doctors, prosthetists and other healthcare providers involved in their amputation care system.
What Every Medicare Patient With Limb Loss Should Know
- Do you know the K-level your physician has determined for you? This will be a number between 0 and 4.
- Has your physician properly documented in your medical record all of the information needed to determine your K-level? Ask your physician how the documentation supports the need for your prosthesis.
- Be sure your prosthetist fits you with a prosthesis that is appropriate for your K-level.
- Your K-level affects the kind of foot and/or knee your prosthetist can incorporate into your prosthesis.
- Visit your physician regularly (every 6-12 months) to maintain complete documentation of your prosthetic care. Discuss your prosthetic use with your physician, including your current and potential K-level; the condition of your residual limb; your socket fit; how your prosthesis is functioning; and any activities that you are unable to perform in your current prosthesis that you would like to be able to do.