CPT Documentation & Record Keeping 3 — Questions and Answers
Question 1: A prior authorization for a prosthetic device expires before delivery is completed. What is the correct action?
- Deliver the device and bill anyway
- Request a new or extended authorization before delivery (Correct answer)
- Backdate the delivery to within the authorization period
- Bill under a different HCPCS code
Correct answer: Request a new or extended authorization before delivery
Delivering and billing for a device after prior authorization has expired can result in claim denial and fraud allegations; a new authorization must be obtained.
Question 2: Which HCPCS code category is used for most lower-limb prosthetic devices billed to Medicare?
- E codes
- L codes (Correct answer)
- A codes
- K codes
Correct answer: L codes
L codes (L5000–L5999) are the HCPCS Level II codes designated for lower-limb prosthetic devices.
Question 3: What is the purpose of a functional outcomes assessment tool like the PLUS-M in prosthetic documentation?
- To calculate reimbursement rates
- To objectively measure the patient's prosthetic mobility (Correct answer)
- To document the technician's fabrication steps
- To verify insurance eligibility
Correct answer: To objectively measure the patient's prosthetic mobility
The PLUS-M (Prosthetic Limb Users Survey of Mobility) quantifies a patient's functional mobility, supporting clinical justification in the medical record.
Question 4: When a prosthetic component is replaced under warranty, which documentation is still required?
- A new prescription and updated medical necessity documentation (Correct answer)
- Only the warranty claim form from the manufacturer
- A patient complaint letter
- A duplicate of the original delivery receipt
Correct answer: A new prescription and updated medical necessity documentation
Even warranty replacements require updated documentation including a new or reaffirmed prescription and evidence of continued medical necessity.
Question 5: In prosthetic records, 'episode of care' documentation typically ends when:
- The patient pays their copayment
- The patient achieves functional goals or is discharged (Correct answer)
- The technician completes fabrication
- The insurance claim is paid
Correct answer: The patient achieves functional goals or is discharged
An episode of care is closed when the patient achieves stated functional goals or is formally discharged from prosthetic care.
Question 6: A technician notices that a co-worker has been entering fabrication times that appear inflated. The correct response is to:
- Correct the entries without informing anyone
- Report the concern through the facility's compliance process (Correct answer)
- Ignore it as it is not the technician's responsibility
- Adjust the technician's own records to match
Correct answer: Report the concern through the facility's compliance process
Suspected fraudulent documentation must be reported through the facility's compliance or ethics reporting process to protect the patient and organization.
Question 7: Which of the following best supports the medical necessity of a dynamic response prosthetic foot?
- The patient's preference for an aesthetic cover
- Documented functional goals requiring energy return during ambulation (Correct answer)
- The lower cost compared to a SACH foot
- The prosthetist's personal preference
Correct answer: Documented functional goals requiring energy return during ambulation
Documented functional goals and activity level expectations are the clinical basis for justifying an energy-storing/returning foot over a standard device.
CPT Documentation & Record Keeping 3
A prior authorization for a prosthetic device expires before delivery is completed.
What is the correct action?