Responses to my brace and limb maker question
Michael Kiser,C.O.
Description
Collection
Title:
Responses to my brace and limb maker question
Creator:
Michael Kiser,C.O.
Date:
2/17/2013
Text:
My original question was:
My question is regarding RAC audits and Medicare requiring more information
as well as future requirements for documentation. Is it time to push for
reimbursement for our extensive evaluations. We are documenting muscle
testing, ROM, doing quantifiable, written, reproducible gait analysis and
outcome measurements in a printable form that is shared with Physicians,
PTs, OT and the rest of the medical community. Is it time that we, (at least
the ones of us that are doing it), insist to be recognized as clinicians
instead of brace and limb makers and be paid for our evaluations. I know
that I am not the only one that is up at 4:00am fulfilling our compliance
from the previous day. I know my notes of 10 years ago were lacking and I
could have been considered a brace maker. But now I am definitely a
clinician. My ABC facility inspector 10 years ago told me that my notes were
the average in the industry at that time and inadequate. I greatly improved
but not near the level that I am now. My evaluations now all include
documented Muscle tests on both limbs, Range of motion, electronic gait
analysis, quantifiable and reproducible outcome measures and much more. This
is an insult to be in the group of DME when our documentation is at the very
least equal to PT and in most cases exceeds theirs. This is all necessitated
by the unfair RAC audits. The vehicle that guides me to this level of
documentation is OPIE. I can't believe that as of now we can't bill for this
level of patient care. We are all documenting to a level that has not been
necessary in the past but is now necessary as we are assumed to be frauds
prior to providing service. What do you think? Are we brace and limb makers
or clinicians?
Should we be able to bill the payers that are necessitating this extra
diligence?
Mike Kiser, C.O.
A sampling of the responses are:
----------------------------------------------------------------------------
Your question is one that has been brought up on many occasions over the
years and in fact I once asked the same one. Here is what I was told by
those who had been around a lot longer than me and their answer is why I
personally never pushed the issue. Consider for arguments sake what
physicians, PT's and the like are paid for their professional time to do
evaluations and the like. Now, I am not saying consider what they bill for
but what insurance companies actually allow them for such professional
services. From what I can see they are paid a fraction of what they actually
bill. Now, ask yourself if we O and P clinicians
were to be able to bill for our professional evaluations on a separate line
item what would or could we expect to get for our time? Now, if indeed we
were paid separately for our professional time what do you think we could
then expect to get paid for the item that we would then be fitting to a
patient? My guess it that payers would ask or demand to see the actual cost
of the item and then they would then most likely add a nominal percentage of
gross profit to it and that is what we would then get for the item or
product we ultimately fit to our patient. Presently, we are paid a fee which
is supposed to include all of the above. My problem will always be relative
to those who provide a product and are then paid fees for said products
while skipping or minimizing for whatever reason, the related clinical
components of the procedure that patients deserve.
----------------------------------------------------------------------------
Mike it is my understanding that years ago we shot ourselves in the foot on
this. As I understand it there was a fork in the road one was the clinical
path and one was the product. O&P leadership at the time took us down the
product path because they saw it as more profitable anyway that it how I
understand it.
Also the procedure codes (L-codes) that were developed out of an AOPA
business committee were taken over by CMS whereas the procedure codes used
by physicians are still controlled by the AMA.
----------------------------------------------------------------------------
I understand your frustrations and I could not have agreed more with your
statement. I have been in the field for close to 30 years, and yes, my
evaluations are getting more lengthy and detailed. Considering that
therapist can fit an orthosis and bill for the L code and bill for their
evaluations on the same patient irks me to no end. This alone has been a
topic of debate with Medicare for years with no results due to the strength
in numbers per say that therapist have. In the eyes of the medical community
we are limb makers. We can only blame ourselves for this perception that we
have created. I have tried to spearheaded this a while back with cms and got
mugged by the lawyers representing the therapist. Guess who won? Funny thing
is my argument was simple and cost savings to cms. And still I got no where.
So...yes we are limb makers.
----------------------------------------------------------------------------
I agree with you. Like you, being up at 4am isn't going to cut it
much longer. I think the question is how. I am president of our state O&P
association here in Oklahoma and I am thus in a position to help in this
area, as I think many of us are. Unfortunately I don't even know where to
start. I also think we need to edit our state licensure laws to govern all
who provide O and P instead of only governing those who call themselves
orthotists and prosthetists. We would have to do this in a way that does not
anger those PT's doctors, and groups who are already our competition in
certain areas of practice. This might mean leaving out most orthotic
devices in order to salvage those products which we still have a control of.
Mostly this would be custom lower and upper extremity prosthetics and some
orthotic devices including scoliosis and cranial orthotics. Thank you for
posting this, please keep in touch, I plan on posting in regards to this
matter as well. Unfortunately, no matter what you, I a;nd others may think,
CMS has other ideas. Our notes can only be used against us and not to
support what we have done. CMS states specifically that suppliers notes are
not part of the medical record! As I see it, it will need to be congress who
addresses whether we are clinicians or technicians and I don't believe that
we as a group have either the backbone or the inclination to pursue that.
We keep referring to the unfair audits. The mechanism for these audits has
been on the books for many years. Audits are not unusual in any publically
funded endeavour. We should have been all over these regulations as they
were promulgated and not have allowed them to be on the books without
protest. This should have been done at the national level (read AOPA, NAAOP,
AAAOP, and yes I left out ABC because it only takes our money to be able to
protect consumers). We pay huge sums to these organizations. Where are they?
OPGA has done a hell of a job in publishing a White Paper; what have the
others done?
There are so many issues that need to be addressed and clinician vs
technician is but one. This is not to dismiss you question, but rather to
put it in perspective.
----------------------------------------------------------------------------
My question to you is this. Are you like me and have patients come in for an
evaluation to see what you would suggest? Do you see anything in the
requirements that would prevent us from charging a fee for this evaluation?
I have never seen anything that would prevent us from charging the patient
for an evaluation that leads to the fitting of a brace be it custom or
prefab. The PDAC narrative only includes fitting and adjustment, no mention
of an evaluation. I know we cannot charge for travel time, but my
evaluations are certainly worth money. I certainly believe we should be
compensated, but I have found that patient will pay out of pocket if you
educate them about their condition and are professional. I have heard a
thousand times, you have just explained more than any doctor or therapists
has! I'm sure you have heard this too!
----------------------------------------------------------------------------
Well the summary in my mind after reading the many insightful responses is
that we need to persevere with the most complete evaluations, design,
fittings and follow up within our ability. Share them with the patients
whole healthcare team and eventually the perceptions regarding us will
raise. At the very least we will grow in our patient care skills. If we
receive an Rx make a device and follow up as necessary with no meaningful
communication then we stay where we are. The RAC audits may have a hidden
opportunity to demonstrate our clinical skills of evaluation and
documentation to the auditors and hopefully Medicare or it can demonstrate
our inability to be true clinicians and that we are brace and limb makers. I
hope it is not the latter. Thanks Again,
Mike
My question is regarding RAC audits and Medicare requiring more information
as well as future requirements for documentation. Is it time to push for
reimbursement for our extensive evaluations. We are documenting muscle
testing, ROM, doing quantifiable, written, reproducible gait analysis and
outcome measurements in a printable form that is shared with Physicians,
PTs, OT and the rest of the medical community. Is it time that we, (at least
the ones of us that are doing it), insist to be recognized as clinicians
instead of brace and limb makers and be paid for our evaluations. I know
that I am not the only one that is up at 4:00am fulfilling our compliance
from the previous day. I know my notes of 10 years ago were lacking and I
could have been considered a brace maker. But now I am definitely a
clinician. My ABC facility inspector 10 years ago told me that my notes were
the average in the industry at that time and inadequate. I greatly improved
but not near the level that I am now. My evaluations now all include
documented Muscle tests on both limbs, Range of motion, electronic gait
analysis, quantifiable and reproducible outcome measures and much more. This
is an insult to be in the group of DME when our documentation is at the very
least equal to PT and in most cases exceeds theirs. This is all necessitated
by the unfair RAC audits. The vehicle that guides me to this level of
documentation is OPIE. I can't believe that as of now we can't bill for this
level of patient care. We are all documenting to a level that has not been
necessary in the past but is now necessary as we are assumed to be frauds
prior to providing service. What do you think? Are we brace and limb makers
or clinicians?
Should we be able to bill the payers that are necessitating this extra
diligence?
Mike Kiser, C.O.
A sampling of the responses are:
----------------------------------------------------------------------------
Your question is one that has been brought up on many occasions over the
years and in fact I once asked the same one. Here is what I was told by
those who had been around a lot longer than me and their answer is why I
personally never pushed the issue. Consider for arguments sake what
physicians, PT's and the like are paid for their professional time to do
evaluations and the like. Now, I am not saying consider what they bill for
but what insurance companies actually allow them for such professional
services. From what I can see they are paid a fraction of what they actually
bill. Now, ask yourself if we O and P clinicians
were to be able to bill for our professional evaluations on a separate line
item what would or could we expect to get for our time? Now, if indeed we
were paid separately for our professional time what do you think we could
then expect to get paid for the item that we would then be fitting to a
patient? My guess it that payers would ask or demand to see the actual cost
of the item and then they would then most likely add a nominal percentage of
gross profit to it and that is what we would then get for the item or
product we ultimately fit to our patient. Presently, we are paid a fee which
is supposed to include all of the above. My problem will always be relative
to those who provide a product and are then paid fees for said products
while skipping or minimizing for whatever reason, the related clinical
components of the procedure that patients deserve.
----------------------------------------------------------------------------
Mike it is my understanding that years ago we shot ourselves in the foot on
this. As I understand it there was a fork in the road one was the clinical
path and one was the product. O&P leadership at the time took us down the
product path because they saw it as more profitable anyway that it how I
understand it.
Also the procedure codes (L-codes) that were developed out of an AOPA
business committee were taken over by CMS whereas the procedure codes used
by physicians are still controlled by the AMA.
----------------------------------------------------------------------------
I understand your frustrations and I could not have agreed more with your
statement. I have been in the field for close to 30 years, and yes, my
evaluations are getting more lengthy and detailed. Considering that
therapist can fit an orthosis and bill for the L code and bill for their
evaluations on the same patient irks me to no end. This alone has been a
topic of debate with Medicare for years with no results due to the strength
in numbers per say that therapist have. In the eyes of the medical community
we are limb makers. We can only blame ourselves for this perception that we
have created. I have tried to spearheaded this a while back with cms and got
mugged by the lawyers representing the therapist. Guess who won? Funny thing
is my argument was simple and cost savings to cms. And still I got no where.
So...yes we are limb makers.
----------------------------------------------------------------------------
I agree with you. Like you, being up at 4am isn't going to cut it
much longer. I think the question is how. I am president of our state O&P
association here in Oklahoma and I am thus in a position to help in this
area, as I think many of us are. Unfortunately I don't even know where to
start. I also think we need to edit our state licensure laws to govern all
who provide O and P instead of only governing those who call themselves
orthotists and prosthetists. We would have to do this in a way that does not
anger those PT's doctors, and groups who are already our competition in
certain areas of practice. This might mean leaving out most orthotic
devices in order to salvage those products which we still have a control of.
Mostly this would be custom lower and upper extremity prosthetics and some
orthotic devices including scoliosis and cranial orthotics. Thank you for
posting this, please keep in touch, I plan on posting in regards to this
matter as well. Unfortunately, no matter what you, I a;nd others may think,
CMS has other ideas. Our notes can only be used against us and not to
support what we have done. CMS states specifically that suppliers notes are
not part of the medical record! As I see it, it will need to be congress who
addresses whether we are clinicians or technicians and I don't believe that
we as a group have either the backbone or the inclination to pursue that.
We keep referring to the unfair audits. The mechanism for these audits has
been on the books for many years. Audits are not unusual in any publically
funded endeavour. We should have been all over these regulations as they
were promulgated and not have allowed them to be on the books without
protest. This should have been done at the national level (read AOPA, NAAOP,
AAAOP, and yes I left out ABC because it only takes our money to be able to
protect consumers). We pay huge sums to these organizations. Where are they?
OPGA has done a hell of a job in publishing a White Paper; what have the
others done?
There are so many issues that need to be addressed and clinician vs
technician is but one. This is not to dismiss you question, but rather to
put it in perspective.
----------------------------------------------------------------------------
My question to you is this. Are you like me and have patients come in for an
evaluation to see what you would suggest? Do you see anything in the
requirements that would prevent us from charging a fee for this evaluation?
I have never seen anything that would prevent us from charging the patient
for an evaluation that leads to the fitting of a brace be it custom or
prefab. The PDAC narrative only includes fitting and adjustment, no mention
of an evaluation. I know we cannot charge for travel time, but my
evaluations are certainly worth money. I certainly believe we should be
compensated, but I have found that patient will pay out of pocket if you
educate them about their condition and are professional. I have heard a
thousand times, you have just explained more than any doctor or therapists
has! I'm sure you have heard this too!
----------------------------------------------------------------------------
Well the summary in my mind after reading the many insightful responses is
that we need to persevere with the most complete evaluations, design,
fittings and follow up within our ability. Share them with the patients
whole healthcare team and eventually the perceptions regarding us will
raise. At the very least we will grow in our patient care skills. If we
receive an Rx make a device and follow up as necessary with no meaningful
communication then we stay where we are. The RAC audits may have a hidden
opportunity to demonstrate our clinical skills of evaluation and
documentation to the auditors and hopefully Medicare or it can demonstrate
our inability to be true clinicians and that we are brace and limb makers. I
hope it is not the latter. Thanks Again,
Mike
Citation
Michael Kiser,C.O., “Responses to my brace and limb maker question,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/234739.
