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NAAOP Responds to Proposed Clinical Template for Medicare Prosthetic Claims

The Centers for Medicare and Medicaid Services (CMS) has decided to develop and implement an electronic clinical template for lower limb prostheses for the purposes of attempting to inform the health care community what level of documentation is needed to support the medical necessity of Medicare claims for lower limb prostheses.

In theory, informing prosthetists and physicians what CMS and its contractors expect to see in order to make coverage and payment decisions for prosthetic care is not a bad thing. However, NAAOP has deep concerns with CMS’s proposed approach. In fact, NAAOP and many of its members participated in the first Open Door Forum that CMS held on this issue on May 28, 2013 and, in concert with the O&P Alliance, will submit detailed comments to CMS on this clinical template.

The proposed documentation template is geared solely toward physicians and again fails to recognize the value and relevance of the prosthetist’s clinical file and patient care notes. In fact, the template solidifies reliance on the medical information recorded by the physician and fails to accord proper weight to the functional status and functional potential of the patient.

Under Medicare law, a strong argument can be made that prosthetists’ clinical notes are clearly part of the medical record that help determine the medical necessity of prosthetic care, but ever since CMS publication of the “Dear Physician” letter in August 2011, CMS has not considered prosthetists’ notes as part of the medical record. This has resulted in major upheaval in the O&P profession through the imposition of extensive auditing activity by RACs and other Medicare contractors. NAAOP, in concert with the O&P Alliance organizations, has been actively working with CMS to correct this problem ever since.

By developing a clinical template that is geared toward physician documentation of lower limb prosthetic claims, CMS is missing the opportunity to implement the tools it already has available to it to reign in overutilization. CMS has failed to implement BIPA Section 427, the federal law that restricts Medicare payment for custom orthotics and prosthetics to only “qualified” practitioners and suppliers. NAAOP will continue to make these arguments to compel CMS to finally implement these regulations.

The next CMS Electronic Clinical Template for Lower Limb Prosthesis Open Door Forum is scheduled for June 13, 2013 from 4:00 PM - 5:00 PM EST. Dial conference call number: (800) 837-1935 & Passcode: 75399655. Review the Suggested Electronic Clinical Template Elements for Medical Documentation Submitted to CMS in Support of Claims for Lower Limb Prostheses in preparation for the call.

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