I can not believe that I am headed to an ALJ hearing over a pair of diabetic shoes.
Patient ‘X’ was a pre-payment review and the paperwork was denied for lack of a signature log for the physician. – The notes had the the obviously similar signature on the Diabetic Verification form with the MD’s name printed below and date along side the signature.
A redetermination request was made with an additional signed statement from the MD stating those were his notes, the patient has poor circulation, and he needs diabetic shoes…with the signature of the physician, printed name, and date. Along with the MD’s notes and signature attestation was a detailed RX signed & dated with name printed below the signature itemizing the codes and quantity, diagnoses, expected use and duration, patient name, dob, address, and date from the prescribing DPM with his clinical notes, a detailed diabetic verification form with the MD signature, printed name, and date, – completed with the MD’s clinical notes matching the check boxes, photographs of the patient and their feet to show the issue, our clinical in-person evaluation notes, our clinical in-person delivery notes, our in-person follow up notes, all told 34 pages of documentation.
This was now rejected with the auditor reporting the notes did not provide evidence it met the LCD and Policy Article….AND the signature was illegible.
I called Medicare to ask the reasons for rejection and they looked up the file along with all documents submitted…after 20 minutes on hold, I was told the DPM’s notes were more than the MDs notes and the MD did not have enough evidence of need to meet the LCD and Policy Article.
The MD’s notes under EXAM read “Decreased Pulses – Feet” ,under ASSESSMENT is clearly printed “DM with PVD”, under DIAGNOSIS is listed 250.00, and RECOMMENDATION is listed ‘RX Diabetic Shoes – Therapeutic Shoes”. – with the MD’s signature and date on the note.
The person at CGS could see what was submitted and the specific points above but maintained those specifics were not enough to meet the LCD and Policy Article but I had appeal options if I so chose.
Yes, I will appeal.
I worked hard for the money…I provided an important, valuable, high quality service to a Medicare beneficiary to protect them from ulcerations and possible amputation, which would cost Medicare far more than a simple pair of shoes and inserts.
Never let a rejection go uncontested. When you do, they see it as you never should have had the payment in the first place.
The only way to get this to stop is for all of us to contact each of our elected representatives and get a fix legislatively…..as the hospitals seem to have been able to do in modifying their RAC audits.
Brett R. Saunders, CPO, FAAOP
[email protected]
761 County Road 466
Lady Lake, FL 32159
(352) 259-9749 Phone
(352) 259-8209 Fax
