The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) published a revised Dear Physician letter on November 13 that addressed the Medicare requirements for documentation within the referring physician’s medical records. As in the October revision the physician’s documentation must support the medical necessity of O&P services provided to Medicare beneficiaries, but the latest revision includes definitions of the functional levels and specific information about the patient that must be included.
The letter states that the physician must document the patient’s overall health to support his or her assigned functional level, including symptoms that limit ambulation or dexterity, ambulatory assistance in addition to the prosthesis or that they used prior to amputation, comorbidities and the ability to use a prosthesis, a summary of the patient’s activities of daily living, and a physical examination that is relevant to functional deficits.
The letter also says that “the O&P supplier’s notes are expected to corroborate and provide details consistent with your (physician/practitioner) records. In the event of a conflict between your notes and the O&P supplier’s record, the DME MAC would likely deny payment.”
According to a statement about the revision, the American Orthotic and Prosthetic Association (AOPA) said it 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.” However, AOPA states, it is “quite concerned by [the] letter’s assertion that prior and concurrent patient use of ambulatory aids (canes, walkers, crutches and wheelchairs) is in any sense a significant consideration in determining a patient’s functional level,” pointing out that a similar consideration was included in the July 2015 Draft Local Coverage Determination that was rejected by the CMS Interagency Workgroup in June.
To read the latest revision to the Dear Physician Letter, visit the CGS website.
