• Login

    • Year: 2018

    Latest Blog

    Medicare Expands Prior Authorization: Five Codes Added

    Friday, Jan 23, 2026

    DME MACs Announce the Retirement of the Dear Physician Letter for Artificial Limbs

    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.

    Additional TPE Program Results Reported by Noridian

    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.

     

     

    Initial Report on TPE Program Suggests Positive Results

    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.

    AOPA-Funded Systematic Review is Now Complete

    In 2015 AOPA awarded a grant to Michael Dillon, PhD of La Trobe University for his project “Evaluating outcomes of dysvascular partial foot and transtibial amputation: a systematic review for the development of shared decision making resources”. The project has now been completed and the research team accomplished the following:

    • registered the systematic review protocol with PROSPERO
    • published six articles in peer reviewed journals including: o a systematic review protocol (available as open access)
    • two systematic reviews (both available as open access),
    • an expert clinical view point describing the development of the decision aid and discussion guide
    • two translational pieces challenging long held views about the association between amputation level and mortality rates, as well as increasing amputation prevalence
    • written the first decision aid and discussion guide to help support decisions about dysvascular amputation
    • translated this work through seven keynote/invited addresses
    • published translational pieces for online magazines such as O&P Almanac and Amplified –

    Publications below:

    AOPA Confirms K0903 Medicare Fee Schedule at Same Rate as A5513

    Recently, AOPA announced an important Advocacy victory regarding the Medicare fee schedule amount for K0903, the newly created HCPCS code used to describe direct milled, custom fabricated diabetic inserts.  When K0903 was first announced, CMS indicated that the Medicare fee schedule would be approximately $5.00 less than the current fee schedule for A5513 which describes custom fabricated diabetic inserts molded over a positive model of the patient’s foot.  AOPA challenged this position and presented several arguments that supported the direct crosswalk of the Medicare fee schedule for A5513 to the fee schedule for K0903.

    Last week, AOPA announced that CMS had issued a bulletin indicating that the fee schedule for K0903 would be set at $43.56, the current Medicare fee schedule for A5513.  CMS has released the Medicare fee schedule update for April 1, 2018 and AOPA has confirmed that the Medicare allowable for K0903 has indeed been established at $43.56, the identical fee schedule amount for A5513.

    AOPA is proud of this advocacy victory, not only for what it represents for providers of diabetic inserts, but also for the precedent that it sets for future issues involving the use of scanning and other technology to create alternate manufacturing processes in orthotics and prosthetics.

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

    AOPA Secures an Advocacy Victory on Reimbursement for Custom Fabricated, Direct Milled Diabetic Inserts

    AOPA is very pleased to announce an advocacy win regarding the fee structure for K0903/A5513. AOPA has confirmed with the Centers for Medicare and Medicaid Services (CMS) that the Medicare fee schedule for K0903, a temporary HCPCS code, effective April 1, 2018, that describes custom fabricated, direct milled diabetic inserts has been set at the same amount as the current Medicare fee schedule for A5513 ($43.56 for most states), which describes custom fabricated diabetic inserts that are fabricated over a positive model of the patient’s foot. This has been a very long battle, one in which AOPA partnered with the American Podiatric Medical Association, the O&P Alliance, and the Amputee Coalition.  This is VERY important because A5513 is not the only code where scanning processes have evolved – this hopefully sets the right precedent for the agency.

    This battle included a decision, first highlighted by PDAC, that diabetic shoes inserts that were fabricated using scanning devices and direct milling did not meet the precise words of the A5513 code, which referenced the process as molded over a model of the patient’s foot. A coding verification notification was initiated by PDAC to focus on the process used. It should be noted that this code, vital to protecting diabetic patients, had declined in utilization by 14% in the prior 3 years, largely because of unreasonable reimbursement cuts. At an Open Door Forum, CMS announced that they agreed that the processes were equivalent, but also said that the scanned device required less work, and they expected to reduce the fee by about $7 for direct milled inserts. A long battle has ensued, where as a result of Congressional pressure, the fee decision was shifted to the very highest levels in CMS. Ultimately, CMS reached the right decision that as the processes were essentially equivalent, the fee needed to also be identical (one of the several arguments AOPA mounted was the CMS’ own manuals say that when one code is “exploded” into two parallel codes both new codes must retain the same fee), as provided in CMS’ own Medicare Claims Processing Manual

    AOPA is proud of this advocacy victory, not only for what it represents for providers of diabetic inserts, but also for the precedent that it sets for future issues involving the use of scanning and other technology to create alternate manufacturing processes in orthotics and prosthetics. AOPA is greatly indebted to Rep. Brad Wenstrup and his excellent staffers – Derek Harley, Nick Uehlecke (Ways & Means Committee) and Greg Brooks for their help, as well as Joe McTernan, Devon Bernard, Ashlie White and others on AOPA’s lobbying team. Believe it or not, this battle started in August, 2017, when we set our strategy, began outreach to podiatrists, and to key Hill players!

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

    So Congress (and the federal law) now says our orthotist/ prosthetist notes are officially part of the medical record for purposes of medical necessity determinations… now what?

    What the new law says
    The statute, as enacted, is comprised of one sentence which states:
    *SEC. 50402. ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES AS PART OF THE PATIENT’S MEDICAL RECORD.  Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph.

     ”(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS.-For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”.

    Some Interim Suggestions for Submitting Claims

    The sentence is unmistakably clear, to the point that it should be self-actuating, becoming actively in force as of the time of enactment. Since there were no regulations changed when the DME MACs changed policy by introducing the August 2011 “Dear Physician” letter, there does not seem any need for regulations to revert back to the previous policy. That being said, CMS often sees things through their own lens, so there is no assurance they won’t issue a regulation of some kind regarding this issue.

    That said, it seems CMS believes it needs to advise its contractors, in this case, the DME MACs, whenever there is a policy change. But before we get to that, here are some general suggestions-not based precisely in the law (which is only one sentence), but some common sense considerations as you submit claims in the interim until the major questions are resolved by some CMS announcement.

    You should consider submitting a copy of the provision with every claim where you include copies of your notes. There is no clarity on timing from Congress. The new law clearly applies to prostheses and orthoses you fit and bill going forward. While the law is mute on intent to retrospective application, we believe it applies to all pending and new claims and appeals. CMS may, or may not announce their comparable view. There is nothing in the provision that says that, so it may take some battles with DME MACs to resolve the retrospective question, but we do have the high ground with a brand new provision.

    Legally, the provision puts things back to where they were before the August 2011 “Dear Physician” letter. Then, the O/P practitioner notes could corroborate and provide additional details consistent with the physician records. The O&P notes cannot alone be the basis for satisfying the Medicare requirements of the prescription-they never could before and can’t now. So, if the physician notes state that an orthotic patient’s symptoms indicate likelihood of knee instability, and the O/P notes say our examination confirmed knee instability, that is probably fine. But if the physician makes no mention of knee instability, legally, the orthotist/prosthetist notes, standing alone, can’t fill in that void.

    The bottom line is while the jury is still out on how this law will ultimately be implemented, there is absolutely no harm in operating under the assumption that the law applies to outstanding appeals. Anything that will increase the chances of acceptance of practitioner records as relevant to payment decisions is a good thing.

    Then, the DME MACs started showing this slide at a training session:
       

    While many were surprised and disillusioned by this slide, this is what government contractors do when faced with change.  They don’t want to take direct responsibility, and put their multi-million dollar contracts at risk.  Rather, they say, “we’re not making any changes, unless and until CMS tells us.”

    AOPA Outreach to CMS
    AOPA is obviously interested in getting unresolved questions resolved, and for CMS to get out word to CMS contractors, and to get things moving as Congress intended.

    On Friday, February 23, AOPA sent a letter from AOPA President Jim Weber and Executive Director Tom Fise to CMS Administrator Seema Verma requesting that the agency resolve the contractor’s questions in order to get the law operational. (Read the letter.)  We expect that this AOPA letter will not be the only one going to the CMS Administrator, because several Members of Congress who helped write and expect Section 50402 to be implemented smoothly and efficiently may also weigh in.  We will continue to keep you informed as these actions unveil further.

    Opportunities for Clinical O&P Research Support from AOPA

    The American Orthotic & Prosthetic Association is proud to announce 5 Requests for Proposals for separate research grants.

    As part of AOPA’s Orthotics 2020 initiative, we are committed to making a major leap forward in clinical research that can answer some of the most important and profound issues about Orthotics. AOPA, together with its many partners among O&P manufacturers, patient care companies, and others entities committed to an evidence-driven future for O&P, will be funding one grant for each topic below in amounts of up to $60,000-$75,000, varying by topic- see each RFP for the specifics of the grant.

    1. Orthotic Treatment for Stroke Patients
    2. Back Bracing
    3. Osteoarthritis of the Knee
    4. Orthotic Treatment for Plagiocephaly in Pediatric Patients
    In partnership with the Center for O&P Learning & Evidence-Based Practice (COPL), AOPA is accepting applications for pilot grants for up to $15,000-$30,000 for ten O&P topics, including an open topic (multiple grants will be funded).
    • Pilot Grant RFP

    The deadline for all proposals is April 30, 2018. If you have any questions, please contact Yelena Mazur at ymazur@aopanet.org or 571/431-0876.

    FAQ
    Q: Do you have to live in the US to be eligible?
    A: No, the grant is open to researchers from any country.

    Q: Does the grant include funding for the salary of the Principle Investigator?
    A: For the Pilot Grants (up to $15-30,000), the budget does not allow for salary for the PI. For the Orthotics 2020 grants, the budget can include salary.

    Update: Orthotist/prosthetist notes will be considered part of the patient’s medical record by CMS!

    It’s official! As a follow-up to yesterday’s announcement, with the overnight action of both Senate and House in enacting the Continuing Resolution and the spending bill, and with President Trump having signed that legislation, not only is the federal government open, but the following O&P provision is now officially signed into law:

    SEC. 50402. ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES AS PART OF THE PATIENT’S MEDICAL RECORD.
    13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph:”
    (5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS. – For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”.

    Even with this one sentence, straightforward provision, there may be questions of timing applicability and such to be resolved – but the win is complete. The Orthotist and Prosthetist Notes are now officially part of the medical record for purposes of Medicare medical necessity and claims audits!

    Join us at the 2018 Policy Forum to advocate for the other provisions of the Medicare O&P Improvement Act, Veterans’ choice, and more. Learn more and register.

    A Legislative win for O&P

    The Continuing Resolution/Spending Bill that is moving through Congress to keep the government open has provided the means to accomplish one of the key components of the O&P Medicare Improvements Act, which AOPA, its lobbyists, its members, and MANY important friends in O&P have been fighting for several years!

    The legislation set to be enacted by the Senate, moving back to the House, states:
    Your orthotist/prosthetist notes WILL be considered by CMS to be officially part of the patient’s medical record for purposes of medical necessity, and RAC and pre-payment audits!

    Are we certain? There is no certainty until the Senate and House enacts the bill and the President signs it, however, we are in the strongest position ever to believe that this measure, so important to O&P patients and professionals will make its way into law. All of these three steps need to happen before midnight tonight to avoid another government shutdown — and we fully expect all three will happen.

    This provision is NOT the entire Medicare O&P Improvements bill (S.1991/HR2599). In fact the provision is so short that it follows. All these items not enacted are important and valuable provisions, and AOPA, with others will consider the strategy how these might also move forward for the Policy Forum on March 7-8 in Washington.

    SEC. 50402. ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES AS PART OF THE PATIENT’S MEDICAL RECORD. Section 1834(h) of the Social Security Act (42 U.S.C. 1395m(h)) is amended by adding at the end the following new paragraph:
    ”(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS.-For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).”.

    When It Comes to Celebrating….

    In a process that took these several years, it is hopeless to think that we can ever identify everyone, and not miss some important contribution. So, knowing that some are being left out, here are some folks we cannot omit from recognition:

    • Legislative Co-Sponsors: Reps. Glenn Thompson (R-PA), Mike Thompson (D-CA), Mike Bishop (R-MI), Peter King (R-NY), Dutch Ruppersberger (D-MD), Michael Kelly (R-PA). And Senators Chuck Grassley (R-IA), Mark Warner (D-VA), Bill Cassidy (R-LA), Ben Cardin (D-MD), and Tammy Duckworth (D-IL). Senators Orrin Hatch (R-UT), and Ron Wyden (D-OR) of the Senate Finance Committee, and Reps. Kevin Brady (R-TX) and Richard Neal (D-MA) of the House Ways & Means Committee as well as the staff of all the above legislators deserve special recognition.
    • Former Senator Bob Kerrey, Amputee Coalition and its leaders, especially Jack Richmond, Dr. Jeff Cain, and Dan Ignaszewski.
    • AOPA lobbyists Stephanie Kennan, Michael Park and Mark Rayder, with very solid, vigilant and long-standing support from Peter Thomas (NAAOP and O&P Alliance), and former Congressman Scott Klug representing Hanger.
    • O&P Alliance partners: AAOP, ABC, BOC, NAAOP, and all members of the Item Coalition.
    • Current and prior AOPA Presidents, Officers and Board Members who have been steadfast in their support, including a multi-year financial investment in support of this important work.
    • All AOPA members who have attended the AOPA Policy Forum, attended fundraisers sponsored by, or made direct contributions to the O&P PAC, or wrote or visited their legislators to encourage their support, and others, who while not members of AOPA, have done one or more of the above activities.

    Join us at the 2018 Policy Forum to advocate for the other provisions of the Medicare O&P Improvement Act, Veterans’ choice, and more. Learn more and register.