The segment below is directly from the Medicare Manual. Please note the bottom line that states the patient’s record of medical necessity can be impacted by notes by the Orthotist. Every auditor or seminar that I have heard stated that our notes or documentation were meaningless! What is your take? Does this give us more room to question our ability to impact the medical necessity requirements of our patients? Is this a ray of sunlight that says we are more than just “suppliers” throwing braces on people at will?
5. Documentation in the Patient’s Medical Record CMS Manual System, Pub. 100-08, Medicare Program Integrity Manual, Chapter 5, A?5.7 For any DMEPOS item to be covered by Medicare, the patienta?Ts medical record must contain sufficient documentation of the patienta?Ts medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patienta?Ts diagnosis and other pertinent information including, but not limited to, duration of the patienta?Ts condition, clinical course (worsening or improving), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patienta?Ts record; however, neither a physiciana?Ts order, nor a CMN nor a DIF nor a supplier-prepared statement nor p!
hysician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patienta?Ts medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier-prepared statement or physician attestation (if applicable).
The patienta?Ts medical record is not limited to the physiciana?Ts office records. It may include hospital, nursing home, or home health agency records and records from other professionals including, but not limited to, nurses, physical and occupational therapists, prosthetists, and orthotists
Carey Jinright, LO, ATP, MSM
Cross & 3
