Functional Level Classification
An in-person, comprehensive medical assessment to determine the functional capabilities of the member must be performed by a licensed/certified medical professional with expertise in the treatment of amputees prior to the provision of any prosthesis.
The member’s functional level is based on their overall health status, the objective results of the medical assessment and their documented performance using their immediately previous prosthesis (either preparatory or definitive).
Assessment of the member’s functional capabilities must be based on the following classification levels:
||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.
||Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator
||Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.
||Has the ability or potential for ambulation with community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion.
||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.
When submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS codes L5610-L5616, L5710-L5780, L5810-L5840, L5845, L5848, L5856, L5857, L5858, L5859, L5920, L5930, L5950, L5961, L5970-L5987) components must be submitted with modifiers K0 - K4, indicating the beneficiary’s functional level.