If you’ve been in O&P long enough, you’ve likely had this moment: A claim gets denied, and your first reaction is, “But we did everything right.”
Clinically, that may be true.
But doing the right thing and documenting the right thing are not the same, and that gap is where many denials live.
O&P providers deliver high-quality, patient-centered care every day—comprehensive evaluations, appropriate device selection, and outcomes that make a difference.
Yet claims are still denied. Why? Because payers don’t see what you did—they see what’s documented. And if the documentation doesn’t clearly support medical necessity, the claim doesn’t stand. In other words, the story being told in the record often doesn’t match the care that was provided.
Documentation Is the Language of Payment
Documentation is not just a clinical tool, it’s a compliance requirement and a payment driver.
Payers are looking for a clear, consistent narrative that answers the following questions:
- What is the patient’s condition?
- How does it impact function?
- Why is this specific device medically necessary?
- Will the patient use and benefit from it?
If those answers are not clearly supported, the claim is vulnerable no matter how appropriate the care was.
A Real-Time Example: The New Knee LCD
We don’t have to look far to see how this plays out in real time. The recent changes to the knee orthosis LCD have created excitement across the O&P community. Expanded coverage for osteoarthritis knee braces removes the long-standing requirement for documented joint instability and allows more patients to qualify.
On the surface, it feels like things just got easier. But the documentation requirements didn’t go away, they shifted.
Now, coverage depends on clearly documenting:
- Osteoarthritis supported by imaging
- Functional limitation
- Pain impacting mobility
- A detailed physical exam
- Patient ability and willingness to use the brace
This is the documentation disconnect in action. The opportunity is real, but only if the documentation tells the full story in a way that aligns with the policy.
A Lesson from Outside of Healthcare
Recently, I went through the process of getting approval for a pool through my community’s architectural review board, which I expected to be a completely different world than Medicare.
But as I worked through the application, I did exactly what I’ve done for over 30 years working with Medicare: I read every word of the requirements carefully. And then I used their words. Every requirement they listed, I responded to directly. I organized everything into clear, easy-to-find exhibits so there was no guesswork.
The result? I received approval without delays or any need for back-and-forth communications.
It reinforced something I’ve seen time and time again: Whether you’re working with an architectural review board or Medicare, success comes from understanding the requirements and making it easy for the reviewer to say yes.
Bridging the Gap
In O&P, we often know what the payer requires but we don’t always present it in a way that makes it easy to validate. We assume the reviewer will connect the dots. We assume the documentation speaks for itself.
But strong documentation should:
- Use the same language as the policy or LCD
- Clearly address each requirement
- Be easy to review and verify
- Leave no room for interpretation
Because at the end of the day, we’re not just documenting care. We’re building a case.
It’s not enough to provide good care—we must prove it. The practices that succeed are not necessarily doing more clinically. They are doing a better job of ensuring their documentation reflects the care they already provide.
Because if it’s not documented clearly, completely, and consistently, as far as payers are concerned it never happened.
I challenge you to go back to your office and audit your osteoarthritis braces against these new standards and see how you do.
Erin Cammarata is president and owner of CBS Medical Billing and Consulting. She can be contacted at erin@cbsmedicalbilling.com.
To read Medicare’s new knee orthosis article, visit cms.gov/medicare-coverage-database/view/article.aspx?articleId=52465.
