CMS Documentation Requirements: Prosthetist Survey Results

In the December 2013 issue of The O&P EDGE, I wrote a Perspective article, " A Call to Action ," in which I encouraged others in the O&P profession to get actively involved in efforts to advocate for change with the Centers for Medicare & Medicaid Services (CMS) regarding Recovery Audit Contractor (RAC) lower-limb prosthetic claim audits, specifically those based on a lack of or inadequate physician documentation. In that column, I suggested several steps that O&P professionals might take, including participation in a CMS documentation requirements survey.

That 12-question survey was created and posted online through Survey Monkey in August 2013 to gather input from prosthetists nationwide about their experiences with CMS documentation requirements for Medicare-covered prosthetic services for individuals with lower-limb amputations. The survey results are reported here and will be communicated to CMS in hopes of influencing its future policies regarding RAC audits, functional level determinations for individuals with amputations, and documentations requirements. A companion survey for physicians was also created, but at the time of this publication, an insufficient number of responses had been received to merit tallying.

Demographics At the time this was written, 60 prosthetists had responded to this online survey. All responses were anonymous, and the geographical location of the respondents is unknown.

When asked, "How many years have you been a certified prosthetist?" 63.4 percent of responses came from professionals with 11 or more years of experience.

"Dear Physician" Letter and Obtaining Physician Documentation The next three questions were specific to CMS' "Dear Physician" letter. When asked, "Are you familiar with the 'Dear Physician' letter published by CMS in August 2011 and its contents?" 95 percent replied "yes." However, only 23.3 percent of the respondents reported that they had either received a copy of the "Dear Physician" letter or were made aware of its contents directly in some other way. Further, 85 percent of respondents indicated it had not been necessary for them to provide an attending physician's documentation to support claims for lower-limb prosthetic services provided to Medicare beneficiaries prior to publication of the "Dear Physician" letter.

Questions five through seven focused on receiving documentation from referring physicians. Only 5 percent of respondents answered affirmatively to the question, "Have you noticed an improvement in the availability of supportive physician documentation regarding lower-extremity amputee functional levels since CMS issued their 'Dear Physician' letter in August 2011?"; 26.7 percent answered "somewhat," and 68.3 percent answered "no."

Consistent with the previous question, only 5 percent of respondents indicated that the current physician documentation they are receiving supports their needs to file Medicare prosthetic claims, while the remaining 95 percent were evenly split between replies of "somewhat" or "no." Additionally, when asked, "Do you have difficulty obtaining supportive documentation from your lower-extremity amputee's physicians?" the majority of survey participants responded either "frequently" or "always." None of the respondents replied "never," which indicates that some level of difficulty is always experienced when physician documentation is requested.

K-level Determinations A few questions were asked about prosthetists' attitudes about K-level determinations. When asked if they thought "it reasonable that CMS values your lower-extremity amputee physician's functional level determination more than yours," 89.7 percent of the respondents answered "no." Responses were also overwhelmingly "no" to a separate question asking whether CMS had ever communicated a standardized and objective process it wanted the prosthetist to use when determining functional level. Not surprisingly, 96.7 percent of respondents agreed "it would be beneficial for CMS, after seeking input from O&P organizations and academia, to establish a standardized and objective method to be used universally to determine functional K-levels for lower-extremity amputees." There was less consensus, however, about who prosthetists thought should be responsible for determining a lower-limb amputee's functional level. Slightly more than half (51.7 percent) of the respondents thought that prosthetists, physicians, and/or physical therapists (PTs) should be able to determine an amputee's functional level. The breakdown of responses was as follows:

Tools Used to Determine K-levels The final question of the survey asked, "Currently, when determining a lower-extremity amputee's potential functional K-level, what process(es) do you employ?" The responses varied significantly in length, content, and tone, and most stated that multiple activities are used to make K-level determinations. The responses were reviewed and categorized into generalized groupings; Table 1 represents a summary of how they ranked from greatest to lowest frequency.

The variety of procedures being employed by prosthetists across the country to determine the potential functional level of an individual with a lower-limb amputation provides strong evidence that no one standardized and objective process is being used, in part because CMS has never established such a process. Also, many prosthetists are still relying on K-level determinations that are performed by someone other than the amputee's referring physician, which is contrary to the directives contained in CMS' August 2011 "Dear Physician" letter. This puts into question what will happen with today's prosthetic Medicare claims should they be audited three years from now.

Each prosthetist is independently choosing what to do based on his or her particular circumstances in an attempt to protect him or herself from future RAC audits and potential reimbursement recoupment. Even though the majority of respondents use the Amputee Mobility Preditor (AMP) test (42 percent), they indicated that these tests were overwhelmingly performed by the patient's prosthetist, with a couple of references to tests conducted by PTs, and none of them were attributed to having been conducted by the patient's attending physician.

While the number of respondents to this survey is not large, I believe it nevertheless represents a trend regarding two main issues related to CMS and how it is currently managing Medicare reimbursements for lower-limb amputees' prosthetic services:

While CMS defined the five K-levels of amputee potential functionality in 1995, it has never created, nor implemented, a standardized and objective process to be used to make functional level determinations for lower-limb amputees. However, nearly 97 percent of this survey's respondents indicated that they would support such an approach. After issuing the August 2011 "Dear Physician" letter, CMS never followed up with prosthetists to ensure that its recommendations addressing physician documentation requirements were being followed. Conclusion CMS needs to work with the O&P community and academia to create or approve a single, standardized, and objective process to be used by CMS-designated clinicians, either prosthetists, physicians, and/or physical therapists, when making K-level determinations for lower-limb amputees. CMS also needs to reevaluate the requirement that relies so heavily on physician documentation for K-level determination as that system is not working.

Only when such a unified functional level determination and documentation process is implemented by CMS will the clouds of mystery and doubt disperse, allowing prosthetists to feel more comfortable when submitting lower-limb prosthetic claims to Medicare without fear of future reimbursement reversals due to RAC audits. If such a change in policy does not take place, then many of us may start conforming to one respondent's approach, which was stated as being, "I determine [the amputee's] potential [functional level] by what causes the least amount of financial exposure to the business...[as] I have no trust in the current CMS system, and I do not have a crystal ball to look into the future to determine what CMS will require in three years!"

Thank you to those who took the time to respond to this survey.

Peter Seaman, CP, CTP, a graduate of Century College, White Bear Lake, Minnesota, works for Independence Prosthetics-Orthotics, Newark, Delaware. He can be reached at linkEmail('jpseaman','aol.com');

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