Medicare, K levels, Requirements
Jim DeWees
Description
Collection
Title:
Medicare, K levels, Requirements
Creator:
Jim DeWees
Date:
1/24/2013
Text:
Hello Everyone,
I am forwarding the information I just received from National Government Services (Anthem), who is the local contracted CMS administrator. After MONTHS of these pre-payment audits, and other kinds of audits, NGS just sent out an email with instructions regarding the K-levels and what documentation MUST be in the patient files. Here is a copy of the email. I know that MOST of us are aware of this by now, but this could possibly help someone on this listserve. It is also a reminder to all of us about what Medicare requires. Thanks Jim DeWees, CP
Select
this link to view e-mail as a Web page, go here.
Documentation for K Levels for
Prosthetics
National Government Services, the Jurisdiction B
Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has
received several inquiries in regards to what documentation must appear in the
medical record to support the K level for prosthetics.
Potential functional ability is based on the
reasonable expectations of the prosthetist, and treating physician, considering
factors including, but not limited to:
The beneficiary's
past history (including prior prosthetic use if applicable); and
The beneficiary's current condition including the
status of the residual limb and the nature of other medical problems; and
The
beneficiary's desire to ambulate.
This information must be documented by the treating
physician and the prosthetist.
The
medical record should reflect that a comprehensive medical assessment has
occurred. The medical record should include, but is not limited to, past
history, current functional capabilities and the beneficiary's expected
functional potential, including an explanation for the difference, if that is
the case. The medical record should establish the severity of the beneficiary's
condition and the immediate and long term need for the prosthetic and the
therapeutic benefits the beneficiary is expected to realize from its use. An
entry in the medical record of therapeutic effectiveness or benefit based on
speculation or theory alone cannot be accepted. When restoration of function is
cited as a reason for use of the prosthetic, the exact nature of the deformity
or medical problem should be clear from the medical evidence submitted. Also,
the manner in which the prosthetic will restore or improve the bodily function
should be explained by the treating physician. The K-level selected must be
consistent with the overall health status of the beneficiary.
Coverage is extended only if there is sufficient
clinical documentation of functional need for the technologic or design feature
of a given type of prosthetic.
Note:
Suppliers are reminded per the Centers for Medicare & Medicaid Services
(CMS) Internet-Only Manual (IOM) Publication 100-08, Program Integrity
Manual, Chapter 5,
Section 5.7-5.9, supplier-produced records, even if signed by the ordering
physician, and attestation letters (e.g. letters of medical necessity) are
deemed not to be part of a medical record for Medicare payment
purposes.
This email was sent to:
<Email Address Redacted>
This email was sent by: National
Government Services, Inc.
8115 Knue Rd Indianapolis, IN 46250 United States
CONFIDENTIALITY NOTICE: This e-mail message, including any
attachments, is for the sole use of the intended recipient(s) and may contain
confidential and privileged information or otherwise be protected by law. Any
unauthorized review, use, disclosure or distribution is prohibited. If you are
not the intended recipient, please contact the sender by reply e-mail and
destroy all copies of the original message. Update
Profile | One-Click
Unsubscribe
I am forwarding the information I just received from National Government Services (Anthem), who is the local contracted CMS administrator. After MONTHS of these pre-payment audits, and other kinds of audits, NGS just sent out an email with instructions regarding the K-levels and what documentation MUST be in the patient files. Here is a copy of the email. I know that MOST of us are aware of this by now, but this could possibly help someone on this listserve. It is also a reminder to all of us about what Medicare requires. Thanks Jim DeWees, CP
Select
this link to view e-mail as a Web page, go here.
Documentation for K Levels for
Prosthetics
National Government Services, the Jurisdiction B
Durable Medical Equipment Medicare Administrative Contractor (DME MAC) has
received several inquiries in regards to what documentation must appear in the
medical record to support the K level for prosthetics.
Potential functional ability is based on the
reasonable expectations of the prosthetist, and treating physician, considering
factors including, but not limited to:
The beneficiary's
past history (including prior prosthetic use if applicable); and
The beneficiary's current condition including the
status of the residual limb and the nature of other medical problems; and
The
beneficiary's desire to ambulate.
This information must be documented by the treating
physician and the prosthetist.
The
medical record should reflect that a comprehensive medical assessment has
occurred. The medical record should include, but is not limited to, past
history, current functional capabilities and the beneficiary's expected
functional potential, including an explanation for the difference, if that is
the case. The medical record should establish the severity of the beneficiary's
condition and the immediate and long term need for the prosthetic and the
therapeutic benefits the beneficiary is expected to realize from its use. An
entry in the medical record of therapeutic effectiveness or benefit based on
speculation or theory alone cannot be accepted. When restoration of function is
cited as a reason for use of the prosthetic, the exact nature of the deformity
or medical problem should be clear from the medical evidence submitted. Also,
the manner in which the prosthetic will restore or improve the bodily function
should be explained by the treating physician. The K-level selected must be
consistent with the overall health status of the beneficiary.
Coverage is extended only if there is sufficient
clinical documentation of functional need for the technologic or design feature
of a given type of prosthetic.
Note:
Suppliers are reminded per the Centers for Medicare & Medicaid Services
(CMS) Internet-Only Manual (IOM) Publication 100-08, Program Integrity
Manual, Chapter 5,
Section 5.7-5.9, supplier-produced records, even if signed by the ordering
physician, and attestation letters (e.g. letters of medical necessity) are
deemed not to be part of a medical record for Medicare payment
purposes.
This email was sent to:
<Email Address Redacted>
This email was sent by: National
Government Services, Inc.
8115 Knue Rd Indianapolis, IN 46250 United States
CONFIDENTIALITY NOTICE: This e-mail message, including any
attachments, is for the sole use of the intended recipient(s) and may contain
confidential and privileged information or otherwise be protected by law. Any
unauthorized review, use, disclosure or distribution is prohibited. If you are
not the intended recipient, please contact the sender by reply e-mail and
destroy all copies of the original message. Update
Profile | One-Click
Unsubscribe
Citation
Jim DeWees, “Medicare, K levels, Requirements,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/234522.
