On November 13, 2018, the DME MACs published a revised Dear Physician letter that addresses the Medicare requirements for documentation within the referring physician’s medical records that support the medical necessity of orthotic and prosthetic services provided to Medicare beneficiaries. This letter replaces an early Dear Physician letter, issued in August, 2011 that was retired earlier this year as a result of the passage of legislation which AOPA had promoted and lobbied for (Section 50402) that requires Medicare to consider the medical records of orthotists and prosthetists as a legitimate part of the medical record for purposes of claims payment and medical necessity review/determinations.
The newly released letter acknowledges the legislative change that was passed in February, 2018 and reminds physicians that while orthotist and prosthetists notes are now part of the patient’s medical record for purposes of medical necessity review, it emphasizes the continued need for referring physicians to document the medical need for the O&P devices they prescribe. The letter stresses that O&P practitioner notes must “corroborate and provide details consistent with the physician’s records” and that conflicting information in the physician’s notes and O&P practitioner notes may result in claim denial.
The letter continues on to discuss the importance of physician documentation of the patient’s overall health to support their assigned functional level including symptoms limiting ambulation or dexterity, ambulatory assistance that the patient is using either in addition to their prosthesis or that they used prior to amputation, co-morbidities affecting ambulation and the ability to use a prosthesis, a summary of their activities of daily living, and a physical examination that is relevant to functional deficits. AOPA is encouraged by the continued acknowledgement of a patient’s potential as a factor when establishing their appropriate functional level as well as the reminder that bilateral amputees cannot always be strictly bound by functional level classifications.
While the letter certainly is not perfect, AOPA is pleased that the DME MAC Medical Directors have acknowledged the legislative change that requires the recognition of O&P Practitioner notes as part of the medical record. As AOPA has reported in the past, the legislative change does not and was not intended to remove or diminish the role of the physician as a vital partner in the rehab team. In this respect, the legislation generally puts things on documentation back to where they stood in July, 2011 (before that Dear Physician sought to completely eliminate all consideration of the O&P professional’s notes and records)—O&P clinical records are legitimate as consistent with, corroborative of, and fill in additional details in addition to the physician’s prescription and clinical findings submitted to CMS. This matches with the intent of the legislation to acknowledge and recognize the role of the O&P practitioner as a health professional with valuable clinical input on the overall health and prosthetic needs of the Medicare beneficiary.
AOPA is quite concerned by this latest Dear Physician letter’s assertion that prior and concurrent patient use of ambulatory aids (canes, walkers, crutches and wheelchairs) as in any sense a significant consideration in determining a patient’s functional level, This was a central tenet of the July 2015 proposed Local Coverage Determination which was universally criticized by all 80+ witnesses at the public hearing (also for lack of any scientific justification), and which was rejected earlier this year by the CMS Interagency Workgroup’s repudiation of that draft LCD, which also has since been ‘retired.’ Further, multiple scientific studies have shown that ambulatory aids are not necessarily an impediment to function and often improve a patient’s ability to effectively use a prosthesis.
AOPA will review the revised Dear Physician letter and provide any concerns that it has to the DME MAC Medical Directors, and other Medicare authorities.