Tip for Medicare Appeal
Sara Beck
Description
Collection
Title:
Tip for Medicare Appeal
Creator:
Sara Beck
Date:
10/7/2013
Text:
Hello all,
I wanted to share a helpful tip I encountered during a recent RAC audit.
During the ALJ hearing, I pointed out that the LCD
insinuates that it can be the physician OR the prosthetist that documents and
determines the appropriate componentry (knee and feet) of the prosthesis. The LCD (L11453) states “a determination of
the type of knee for the prosthesis will be made by the treating physician
AND/OR the prosthetist based upon the functional needs of the beneficiary.” It goes on to say “this information must be
retained in the physician’s OR prosthetist files.” Never does is say that functional levels and
components MUST be documented by the physician. By highlighting the “or” verbiage within the LCD, the judge agreed that
this is ambiguous and providers can interpret this to mean that the prosthetist
can be the only one to determine the proper knee or foot according to their functional
level assessment; ultimately meaning that the physician is NOT required to
document the necessity of the knee or the feet. This analysis was successful and the judge agreed that physician documentation
concerning the functional level and prosthetic components is NOT required to
determine medical necessity.
In addition, the Medicare Supplier Manual also states that the
patient’s medical record must SUPPORT the medical necessity for the item. It does not say that the medical record must exhaustively prove the necessity; but simply that is must support the medical necessity. “The patient’s medical record is NOT limited
to the physician’s office records…it may include…records from prosthetists, and
orthotists” (Chapter 3 “Documentation in the Patient’s Medical Record). Do not allow Medicare or its contractors to
overlook or dismiss your documentation, the Manual allows for your records to
be admitted as part of the patient’s medical record.
Please contact my website for more additional tips and news concerning Medicare audits: <URL Redacted>
Best,
Sara Beck
San Joaquin O & P
I wanted to share a helpful tip I encountered during a recent RAC audit.
During the ALJ hearing, I pointed out that the LCD
insinuates that it can be the physician OR the prosthetist that documents and
determines the appropriate componentry (knee and feet) of the prosthesis. The LCD (L11453) states “a determination of
the type of knee for the prosthesis will be made by the treating physician
AND/OR the prosthetist based upon the functional needs of the beneficiary.” It goes on to say “this information must be
retained in the physician’s OR prosthetist files.” Never does is say that functional levels and
components MUST be documented by the physician. By highlighting the “or” verbiage within the LCD, the judge agreed that
this is ambiguous and providers can interpret this to mean that the prosthetist
can be the only one to determine the proper knee or foot according to their functional
level assessment; ultimately meaning that the physician is NOT required to
document the necessity of the knee or the feet. This analysis was successful and the judge agreed that physician documentation
concerning the functional level and prosthetic components is NOT required to
determine medical necessity.
In addition, the Medicare Supplier Manual also states that the
patient’s medical record must SUPPORT the medical necessity for the item. It does not say that the medical record must exhaustively prove the necessity; but simply that is must support the medical necessity. “The patient’s medical record is NOT limited
to the physician’s office records…it may include…records from prosthetists, and
orthotists” (Chapter 3 “Documentation in the Patient’s Medical Record). Do not allow Medicare or its contractors to
overlook or dismiss your documentation, the Manual allows for your records to
be admitted as part of the patient’s medical record.
Please contact my website for more additional tips and news concerning Medicare audits: <URL Redacted>
Best,
Sara Beck
San Joaquin O & P
Citation
Sara Beck, “Tip for Medicare Appeal,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/235729.
