New rules from Medicare

New rules from Medicare

Jake Wood, CP

1/25/2013

List server colleagues,
With our difficulties concerning Medicare changes, I decided to connect
directly with Medicare. I have attended most Medicare Webinar's and signed up
for Medicare (Jurisdiction B, Daily news e-mail)( By the way from
anthem.com; BCBS?)
Today I received what I consider new confusing rules for the future that
we need to prepare for. The UPPER CASE PRINT pertain to my concern. This is
copied from Medicare e-mail.
Jake R. Wood C.P., F.A.A.O.P.
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:
    1. The beneficiary's past history (including prior prosthetic use if
applicable); and
    2. The beneficiary's current condition including the status of the
residual limb and the nature of other medical problems; and
    3. 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 THERAPUTIC 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 BODY FUNCTION SHOULD BE EXPLANED 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_
( <URL Redacted>) , 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.

Jake R. Wood C.P., FAAOP
O&P Associates, Inc.
10506 W. Bluemound Rd.
Milwaukee, WI 53226
414-257-2727
414-257-9898 (Fax)
414-315-9749 (Cell)
<URL Redacted>