C2C DENIAL
Jessica Longoria
Description
Collection
Title:
C2C DENIAL
Creator:
Jessica Longoria
Date:
2/27/2014
Text:
Can anyone cite a specific sentence/paragraph in the LCD, Supplier Manual
or Program Medicare Integrity Manual that states physician addendum's can
NOT be used if entry is delayed 10 months? According to my research,
Program Medicare Intergrity Manual, (Pub 100-08, 3.3.2.5*)*
The MACs, CERT, Recovery Auditors, and ZPICs shall NOT consider any
entries that do not comply with the principles listed in section B ....
*B. Recordkeeping Principles *
Regardless of whether a documentation submission originates from a paper
record or an electronic health record, documents submitted to MACs, CERT,
Recovery Auditors, and ZPICs containing amendments, corrections or addenda
must:
1. Clearly and permanently identify any amendment, correction or delayed
entry as such, and
2. Clearly indicate the date and author of any amendment, correction or
delayed entry, and
3. Not delete but instead clearly identify all original content
I have recevied a denial from C2C for a replacement socket. The auditor
initially denied the appeal stating ....prosthestist notes do not address
the beneficiary's functional level. Therefore, medical necessity for the
replacement prosthesis and additionas cannot be established.
Of course, they failed to notice the prosthetist DOES clearly indicate the
patient's functional level. So, I asked for C2C to look at it again since
the prosthetist DOES clearly document the patient's functional level.
After he reviewed it, he sent an email stating they were going to send a
corrected letter to make .... rationale more clear and accurate. In
other words, he is sending a new denial letter with a new reason.
His email further states the reason for the new denial is The physician's
medical note does not support the CPO notes for the reason of replacement.
Although there is an addendun addressing the need, it is dated 10 months
after the assessment of the physciain. This would not be acceptable. The
addendum is not sufficient to support the need at the time of the DOS and
there needs to be documentation from the physician along with the
prosthetist.
The prosthetist notes are very detailed and do document everything
required. The physician's notes and addendum (which follows ALL the rules
in section B) also support the prosthetist's notes.
Any help would be appreciated!
Thank you!
*Jessica Falknor Longoria, CP, CMF*
*Centers for Mobility/A Touch of Pink*
*7777 Southwest Freeway 107*
*Houston, TX 77074*
*713-773-0969*
*www.CentersForMobility.com < <URL Redacted>>*
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should not be sent to the entire oandp-l list. Professional credentials
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or Program Medicare Integrity Manual that states physician addendum's can
NOT be used if entry is delayed 10 months? According to my research,
Program Medicare Intergrity Manual, (Pub 100-08, 3.3.2.5*)*
The MACs, CERT, Recovery Auditors, and ZPICs shall NOT consider any
entries that do not comply with the principles listed in section B ....
*B. Recordkeeping Principles *
Regardless of whether a documentation submission originates from a paper
record or an electronic health record, documents submitted to MACs, CERT,
Recovery Auditors, and ZPICs containing amendments, corrections or addenda
must:
1. Clearly and permanently identify any amendment, correction or delayed
entry as such, and
2. Clearly indicate the date and author of any amendment, correction or
delayed entry, and
3. Not delete but instead clearly identify all original content
I have recevied a denial from C2C for a replacement socket. The auditor
initially denied the appeal stating ....prosthestist notes do not address
the beneficiary's functional level. Therefore, medical necessity for the
replacement prosthesis and additionas cannot be established.
Of course, they failed to notice the prosthetist DOES clearly indicate the
patient's functional level. So, I asked for C2C to look at it again since
the prosthetist DOES clearly document the patient's functional level.
After he reviewed it, he sent an email stating they were going to send a
corrected letter to make .... rationale more clear and accurate. In
other words, he is sending a new denial letter with a new reason.
His email further states the reason for the new denial is The physician's
medical note does not support the CPO notes for the reason of replacement.
Although there is an addendun addressing the need, it is dated 10 months
after the assessment of the physciain. This would not be acceptable. The
addendum is not sufficient to support the need at the time of the DOS and
there needs to be documentation from the physician along with the
prosthetist.
The prosthetist notes are very detailed and do document everything
required. The physician's notes and addendum (which follows ALL the rules
in section B) also support the prosthetist's notes.
Any help would be appreciated!
Thank you!
*Jessica Falknor Longoria, CP, CMF*
*Centers for Mobility/A Touch of Pink*
*7777 Southwest Freeway 107*
*Houston, TX 77074*
*713-773-0969*
*www.CentersForMobility.com < <URL Redacted>>*
********************
To unsubscribe, send a message to: <Email Address Redacted> with
the words UNSUB OANDP-L in the body of the
message.
If you have a problem unsubscribing,or have other
questions, send e-mail to the moderator
Paul E. Prusakowski,CPO at <Email Address Redacted>
OANDP-L is a forum for the discussion of topics
related to Orthotics and Prosthetics.
Public commercial postings are forbidden. Responses to inquiries
should not be sent to the entire oandp-l list. Professional credentials
or affiliations should be used in all communications.
Citation
Jessica Longoria, “C2C DENIAL,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 5, 2024, https://library.drfop.org/items/show/236122.
