Billing and Collections Q&#038;A

Billing for O&P devices and care is complicated. Count on "Got FAQs?" to help ensure you are using the most current information when preparing your claims. This month's column answers your questions about documentation for prosthesis repair and replacement, and the use of electronic document templates for Medicare documentation. Q: I am new to billing for O&P, and the practitioner I work for suggested that I should refer to your past columns as well as ask you any questions I may have. The practitioner is repairing and adjusting prosthetic legs he provided to a Medicare patient two years ago. As far as a Medicare claim is concerned, is it too soon for the prostheses to be replaced, should that be necessary? What documentation is required for repair or replacement? Is a new prescription from the physician required? A: Adjustments and repairs of prostheses and prosthetic components are covered under the original order for the prosthetic device. Medicare payment may be made to replace a prosthetic limb or any part of such a device without regard to continuous use or useful lifetime restrictions if an ordering physician determines that the replacement device or replacement part is necessary. Claims involving the replacement of a prosthesis or major component, such as a foot, ankle, knee, or socket, must be supported by a new physician's order and documentation supporting the reason for the replacement. The reason for replacement must be documented by the treating physician and must be necessary due to a change in the physiological condition of the patient. Examples include, but are not limited to, a change in the beneficiary's weight, residual limb, or functional need; an irreparable change in the condition of the device or in a part of the device that results in the need for a replacement; or, the condition of the device or a part of the device requires repairs, and the cost of such repairs would be more than 60 percent of the cost of a replacement device or, as the case may be, of the part being replaced. You must retain documentation of the prosthesis or prosthetic component replaced, the reason for replacement, and a description of the labor involved irrespective of the time that has passed since the prosthesis was provided to the beneficiary. There are situations in which the reason for replacement includes, but is not limited to, changes in the beneficiary's residual limb or functional need, irreparable damage or wear/tear due to excessive beneficiary weight, or prosthetic demands placed on the device by a very active user. To view this information and the complete Medicare coverage, read the Local Coverage Determination (LCD): Lower Limb Prostheses (L11442), which can be found by visiting www.oandp.com/link/294 Q: I work for an O&P practice that just started using a new practice management system. I was told there are sample templates that can be used for documentation within the patients' files. I worked for another practice in the past and was told that the templates may not be satisfactory Medicare documentation. Please provide your opinion on this. A: If you review the documentation guidelines outlined in the Medicare Supplier Manual , Chapter 3: "the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type of items ordered." According to the Centers for Medicare & Medicaid Services (CMS) guidelines, templates do not qualify as adequate Medicare documentation and are subject to claim denials. The Program Integrity Manual , 3.2.1.1, Progress Notes and Forms, provides further information: "Some templates provide limited options and/or space for the collection of information such as by using 'check boxes,' predefined answers, limited space to enter information, etc. CMS discourages the use of such templates. Claim review experience shows that limited space templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met." Lisa Lake-Salmon is the president of Acc-Q-Data, which provides billing, collections, and practice management software. She has been serving the O&P profession for more than a decade. We invite readers to write in and ask any questions they may have regarding billing, collections, or related subjects. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors. For more information, contact lisa@opedge.com or visit www.acc-q-data.com

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