Month: May 2018

AOPA and its lobbying team have been pressing CMS from all levels, most recently, including consultation with Trump Administration officials at the Office of Management and Budget, to formally implement the provisions of Section 50402 of the Bipartisan Budget Act of 2018 (Public Law 115-123) as it related to the prosthetist’s and orthotist’s clinical notes.  AOPA was encouraged by the DME MAC notification 2-3 weeks ago where the DME MAC Medical Directors announced that they were ‘retiring’ the August 2011 “Dear Physician” letter on Lower Limb Prosthetics.

AOPA would like to share a recent letter from Alec Alexander, CMS’ Director of Program Integrity which indicates that CMS “has issued instruction to the Durable Medical Equipment (DME) Medicare Administrative Contractors (MAC) to implement Section 50402 immediately.”

Section 50402 states:

‘‘(5) DOCUMENTATION CREATED BY

17 ORTHOTISTS AND PROSTHETISTS.—For purposes of

18 determining the reasonableness and medical neces-

19 sity of orthotics and prosthetics, documentation cre-

20 ated by an orthotist or prosthetist shall be consid-

21ered part of the individual’s medical record to sup-

22 port documentation created by eligible professionals

23 described in section 1848(k)(3)(B).’’.

Mr. Alexander’s letter is a clear assertion of CMS’ commitment to acknowledge immediate implementation of the new statutory provisions in Section 50402, accepting the orthotist and prosthetist clinical notes as part of the individual’s medical record as to “determining the reasonableness and medical necessity of orthotics and prosthetics” e.g., functional levels, identification of broken, damaged parts and their repair, and identifying components in a category included in a physician approved detailed written order.  We also suggest that AOPA members consider including a copy of the letter with all claims they file.

AOPA will continue to keep you informed of any developments in this important area.

Click here to view the letter from Mr. Alexander.

To view the DME MAC announcement of the retirement of the Dear Physician letter for lower limb prostheses, click here.

AOPA, under the auspices of its Orthotics 2020 program, circulated a request for proposals early in 2018 relating to 5 subject areas for original orthotic papers, with the original deadline for receipt of applications by April 30, 2018.  Proposals have been received in all five of those categories.  This notification is to announce a re-opening of the opportunity to submit grant applications/extension of the deadline for applications in just two of those topic areas:

Recently, each of the four DME MAC contractors has published a revised version of the Dear Physician letter regarding artificial limbs. The revised version of the letter states that the Dear Physician letter is being retired due to pending guidance from the Centers for Medicare and Medicaid Services (CMS) on potential program changes that may be necessary to implement the recently passed legislation that requires recognition of O&P practitioner notes as part of the patient’s medical record.

The Dear Physician letter for artificial limbs, originally published in August, 2011, fundamentally changed how Medicare claims for artificial limbs were processed. Prior to the 2011 Prosthetic Dear Physician letter, practitioner notes were generally accepted as being valuable when making claim payment decisions. The Dear Physician letter made it clear that for Medicare purposes, “it is the treating physician’s records, not those of the prosthetist’s, which are used to justify payment.” This statement, and the overall tone of the Dear Physician letter lead to years of frustration where the clinical notes of qualified, educated, certified, and often licensed prosthetists, were simply ignored during the claim review process. This exclusion of valuable clinical information lead to higher claim denial rates and unacceptable delays in the appeal process.

With the February, 2018 passage of legislation that now requires documentation created by orthotists and prosthetists to be considered part of the patient’s medical record for medical review purposes, the statement quoted above and other parts of the Dear Physician letter are no longer consistent with the law. The DME MACs have acknowledged this and have decided to retire the 2011 Dear Physician letter for artificial limbs until they receive further guidance from CMS.

While the retirement of the Dear Physician letter does not mean that the DME MACs will no longer require physician documentation to support claims for artificial limbs, it is a clear indication that they acknowledge and understand that the provisions of the original Dear Physician letter are no longer consistent with the law and therefore can no longer be used as the sole justification for denying a Medicare claim. It also indicates that the diligent AOPA efforts to convince CMS to provide guidance on this issue to their DME MAC contractors. While AOPA does not know what that eventual guidance will be, it is clear that CMS is aware of the legislation and intends to provide guidance to the DME MACs regarding the role of O&P practitioner notes in the medical review process.

View a sample of one of the Dear Physician letters indicating its retirement.

Questions regarding this issue may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.

Earlier this week, AOPA provided a summary on the first report of results of Target, Probe, and Educate (TPE) audits by Noridian Healthcare Solutions, the Jurisdiction D DME MAC contractor.

Since AOPA’s initial report which was limited to TPE results for “walking boot” orthoses, Noridian has published additional results for knee orthoses, spinal orthoses, and off the shelf diabetic shoes.

The newly published results by Noridian continue to show significant reductions in improper payment rates than were previously reported through the previous audit process which included an initial probe review followed by widespread pre-payment review.

As previously reported, the improper claim payment rate has dropped to 19% for walking boot style AFOs. New reports published by Jurisdiction D show that TPE audits for spinal orthosis showed a significant improvement with an improper claim payment rate of 34%.  The improper payment rate for off the shelf diabetic shoes has been reduced to only 19%, a tremendous improvement over the almost 100% error rate during probe/widespread review audits.

Unfortunately, the results from the TPE audits for select knee orthosis codes has not improved as much as some of the other areas subject to TPE.  While Noridian reported some improvement with an improper payment rate of 77%, the improper payment rate remains significantly higher than the other services selected for TPE review.  Common errors reported by Noridian for the knee orthosis review included documentation that does not support coverage criteria, incomplete or missing detailed written order, documentation does not support custom fitted criteria, and failure to respond to the request for documentation.

In addition to reporting the results of the initial audits performed under the TPE program, the DME MACs have just released a “Dear Physician” letter for knee orthoses that is designed to educate referral sources about what documentation must exist in their medical records in order to support your claim for a knee orthosis.  AOPA has reviewed the Dear Physician letter and believes it is consistent with existing LCD and Policy requirements for Medicare coverage of knee orthoses.

The TPE program is designed to provide up to 3 rounds of audits with personalized provider education after each round that is designed to address the specific reasons for claim denial.  While there is clearly a need for improvement in documentation practices for knee orthoses, in general, the results published by Noridian are generally encouraging.  AOPA will continue to monitor the DME MAC websites for additional results from the TPE program.

View the TPE Report

View the Physician letter

Questions regarding this issue may be directed to Joe McTernan at jmcternan@AOPAnet.org or Devon Bernard at dbernard@AOPAnet.org.

Noridian Healthcare Solutions, who serves as the Jurisdiction A and Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor, has released results for its initial audits under the Target, Probe, and Educate (TPE) program in Jurisdiction D.  The published results are only for four HCPCS codes selected for the TPE program: L4360, L4361, L4386, and L4387, which all describe walking boot style orthoses.

The results of the TPE audits are encouraging with an improper claim payment rate of 19%. This improper payment rate represents a vast improvement over error rates under the previous audit system which consisted of a probe review followed by a widespread pre-payment review.  Improper payment rates under this program ranged from 66% to 100% for walking boot style orthoses.

While the results did not discuss the reason for the significant reduction in the error rate, it is logical to conclude that the improvements are primarily due to the education efforts that are an integral part of the TPE program. The TPE program is designed to provide up to 3 rounds of audits with personalized provider education after each round that is designed to address the specific reasons for claim denial.

The results published by Noridian are certainly encouraging and AOPA will be monitoring the DME MAC websites for additional results from the TPE program.

View the Noridian publication.