Original question:
Hello All,
We are in the process of appealing an audit for a KAFO for a polio patient we delivered two years ago. Our first appeal was denied due to the physicians records, however our notes and justification are adequate to determine this level of service. My question is as part of the denial they stated:
“Medicare’s regulatory documents require that supplier-produced records, even if signed by the referring physician, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with information in the medical record.”
I thought our records were part of the medical record and used for Medicare payment purposes. I am curious if I am wrong or they are.
We were rarely audited but they are coming fast and furious now, spinal orthoses, AFOs and KAFOs going years back. We have won all appeals except this one.
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Replies:
Hi Kevin,
The problem in this case may be timing. The provision signed into federal law recognizing the clinical notes of orthotists and prosthetists as valid for the purposes of supporting medical necessity was in February of 2018 (I believe it was 2/8/18). If your date of service associated with the audit is prior to that date then this may provide rationale for the denial. I would still appeal the denial though citing the current law:
[cid:a535d369-2fd4-4afd-9fee-07afb0ea9d00]
You also have an added advantage that your notes are co signed by the prescribing physician. However, we always get an independent chart note from the prescribing physician which sets up the medical necessity of the device to combat this type of denial. Reason is even with the new law in place, upon appeal or audit, the reviewer’s interpretation and application of that law may not be in our favor with O and P notes alone. Hope this helps…good luck!
Bill Harding
Team Leader, Quality Management System
Phone: 610-819-6019
Fax: 610-906-1420
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Kevin,
I believe CPOs notes and justifications became part of the medical record in 2018. See the link:
https://urldefense.proofpoint.com/v2/url?u=https-3A__www.aopanet.org_2018_02_update-2Dorthotistprosthetist-2Dnotes-2Dwill-2Dbe-2Dconsidered-2Dpart-2Dof-2Dthe-2Dpatients-2Dmedical-2Drecord-2Dby-2Dcms_&d=DwIGaQ&c=sJ6xIWYx-zLMB3EPkvcnVg&r=KmuawjwNpT9A2bnhzaNVjw8wO7L_TDosEXIk33h_tlw&m=C-K0QV-LJoX67YzjspSOpxHFt6bij85nO17MoAQlN4Y&s=-3OPHRXOf7982TM5VlnpbNhIgTb3PmUN88YHLPunfUw&e=
Lori
Northern Care, Inc.
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kevin,
Our notes must be backed up in the medical record (not ours but MD) showing long term need and or deformity necessitating custom, and weakness and or instability in more than one plane per LCD.
The key word in CMS response is corroboration. We can write the best notes in the world but if MD has nothing we are toast. Last year I had 12 KAFO audits with very good MD documentation and we won 10 appeals. 2 are going to the ALJ and I will win them there but the administration drain is huge. Unfortunately we are basically government contractors and have to suffer with the insane rules.
-Dave
.
“Medicare’s regulatory documents require that supplier-produced records, even if signed by the referring physician, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with information in the medical record.”
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I would contact AOPA
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Kevin
With your notes, send an actual copy of the current ruling and the CMS statement to its effect stating the fact that our records ARE considered
part of the medical record and used with the physician’s clinical records for authorization. Send a copy
of the CMS current status with each CMS patient billing, period..Most of them are idiots anyway…
John Morgan CP, LPO
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Hi Kevin,
It would be really appreciated if you share responses. I try to collect/document all necessary notes to prevent denial or money back.
Regards,
Darya Shahrokhi, CPO
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Kevin,
Great question! I read all about the political articles that said “our notes were now part of the record.†BUT I never saw the LCDs change to reflect these statements. So, we have stuck to the physician record being the sole evidence for medical need. I would love to know your findings but I am afraid that much like, 1) What does Custom Fit really mean? And 2) Who is and is not qualified to do so? I feel that the documentation question rests in the same shadow as these questions. I have chalked it up to another way for CMS not to pay!
I Am Second,
Carey Jinright, LO, MSM
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My understanding is that our notes need to corroborate the physician record. Medicare has told me no practitioner (PT, doctor, nurse) can justify their notes alone since they have a financial interest. Even doctors have to justify with outside testing.
If your physician record does not mention the need for the brace, diagnosis, the brace being ordered plus any issues that you can deduct a custom brace from (so you can argue that documentation) then they will unfortunately deny the claim.
Our notes can expand but there needs to be something in order for the doctor to justify writing the order to begin with and the level of fitting (OTS, custom fit, custom).
We did loose an appeal because there was nothing for level of fitting and this was the explanation I received.
And if the claims are a few years old- they follow the laws that were in place at the time (we found that out at ALJ level)- luckily we won that one.
Good luck! Maybe if we are lucky someday we will be able to write up a form like the PT and have the doctor sign off 🤷â€â™€ï¸
Amanda
Amanda Butler, CPO
Adaptive Prosthetic & Orthotic Technologies, Inc.
T(508) 587-7300
F(508) 587-7330
Abutler@apotech.biz
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I recently attended a CMS seminar in Denver, CO (May 2019). They HAVE NOT
put the legislation into effect and are still NOT ACCEPTING OUR NOTES AS
PART OF THE MEDICAL RECORD. AOPA fought and seems to have lost although
they initially thought they won.
If medical necessity is not backed up in the Physician’s notes, you have
nothing. When responding to an audit, directly to Medicare, I do not even
bother sending our notes and if the physician notes do not justify medical
necessity, we simply do not fit until we can get notes that justify. We
have to protect ourselves or we will continuously fit patients with braces
in good faith and then 3 years later, have it audited and money taken back
if any part of the LCD is not followed.
Good Luck!
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Hi Kevin
You are correct in that your notes are now part of the medical record but your notes do not comprise the medical record. In other words your notes alone are not sufficient. The prescribing physician notes must corroborate yours. In other words you can put together an outstanding evaluation and documentation but if you are audited and the physician notes are not supportive and corroborate yours it’s not a happy ending. If the physician notes are not supportive or if they are notes sent to the physician to review and sign they can reasonably be considered supplier produced records.
As you know, the only document a supplier can provide for a physician to review, sign and date is the DWO.
Feel free to reach out if you would like to discuss.
Thanks
Kev
Kevin Symms CO, BOCPO, LPO
Ph: 952-237-8489
email: KAS@OandPServe.com
https://urldefense.proofpoint.com/v2/url?u=http-3A__www.OandPServe.com&d=DwIGaQ&c=sJ6xIWYx-zLMB3EPkvcnVg&r=KmuawjwNpT9A2bnhzaNVjw8wO7L_TDosEXIk33h_tlw&m=C-K0QV-LJoX67YzjspSOpxHFt6bij85nO17MoAQlN4Y&s=TAtU1Y8wcbBdtx6wQbyK-tDFi11f2fD6WsA-ca8-Skw&e=
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Kevin,
Thank you for sharing your issue with the listserve. When you get responses could you share them with the group? I’m very curious to other’s responses.
Thank you,
Jim
Jim Lawson
Outreach Development Manager
The American Board for Certification
in Orthotics, Prosthetics & Pedorthics
330 John Carlyle St., Suite 210
Alexandria, VA 22314
703-836-7114 ext.220
703-836-0838 (fax)
jlawson@abcop.org
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Hi Kevin
Let me know if you need help. This is what I do.
Take care,
Lesleigh Sisson, CFom
702-400-1661
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I guess we need the physicians notes for corroboration of our findings. I have found physician notes to be woefully inadequate and went ahead and provided my services and justified the need in my notes. I may end up regretting that. We do a lot of custom AFOs and KAFOs. The task of getting the patient to return for adequate justification from physicians is difficult if not impossible in some cases.
When I hear people say Medicare for all would be much better than private insurance, I question that. I have far fewer problems with private insurance. If the diagnosis indicates this level of care is appropriate I get paid. I don’t need physician notes for everything I do and I don’t need to audit those notes for their appropriateness then send the patient back to the physicians with a note explaining to the physician their notes are inadequate. It will probably only get worse with single payer. They appear to look for reasons to deny care.
Good luck out there!
Kevin C. Matthews, CO
Advanced Orthopedic Designs
12315 Judson Road #206
San Antonio, Texas 78233
210-657-8100
210-657-8105 fax
https://urldefense.proofpoint.com/v2/url?u=http-3A__www.advancedorthopedicdesigns.com&d=DwIGaQ&c=sJ6xIWYx-zLMB3EPkvcnVg&r=KmuawjwNpT9A2bnhzaNVjw8wO7L_TDosEXIk33h_tlw&m=C-K0QV-LJoX67YzjspSOpxHFt6bij85nO17MoAQlN4Y&s=H4rzxwO4wLzebj46_evY0kGR4IjWMQ2x4pa6wM6ET90&e=
