Our response to proposed prosthetic LCD changes
Jeff Arnette
Description
Collection
Title:
Our response to proposed prosthetic LCD changes
Creator:
Jeff Arnette
Date:
8/20/2015
Text:
Dear Colleagues,
All of us have become critically aware of the risk our field and the patients we serve are facing. My staff and I have put together a formal response to the CMS LCD draft. After 20 years of dealing with CMS random audits, appeals, and denials, I have had the privilege of meeting and forging relationships with many of the leaders in the CMS audit and proposal process. After a recent conversation with a close colleague who is a CMS division director, it is my belief that many within the CMS system understand the need for O&P separation from DME.
I believe that now is the time to act with one voice for the industry and our patients with the following recommended proposal for a permanent advisory board of fellow Practitioners, Industry VIP's, and amputee advocacy groups.
We humbly submit the following proposal. We request that you read our full proposal after this summary:
1. We suggest that the draft LCD be rescinded, and code changes be delayed in order to allow Industry leaders, Amputee Advocates, and Prosthetic professionals to participate in a workable solution to reduce cost without negative impact to patient care.
1. We suggest that an advisory board of prosthetic clinicians and industry representatives be established to provide advice to CMS on consolidating coding, and coverage determination. Region C has already established a board of qualified, approved industry leaders, clinicians, and amputee advocates.
1. We suggest that CMS permanently and finally separate Orthotic and Prosthetic devices and their respective L-codes from DME MAC. O&P care (with a very few exceptions) requires a highly trained professional to select and provide the necessary care to the patient. Orthotists and Prosthetists should be recognized as the LCMP that they are. Competitive bidding DME items should be placed under a separate coding structure, as these items require limited training or experience.
Please read the full proposal below.
Sincerely,
Jeff Arnette, CPO, LPO
Member of Region C Provider Outreach & Education Orthotic & Prosthetics Advisory Group< <URL Redacted>>
Progressive Prosthetics www.progressivepo.com
CMS directors
Attn: Stacey Brennan, MD
RE: Proposed LCD DL33787
Dear CMS Directors,
In regards to recent proposed changes in the CMS coverage of orthotics and prosthetics, Orthotists and Prosthetists have come together to unite with one voice for maintained coverage to CMS beneficiaries and reduction in overall cost of prosthetic care. We understand CMS Goals in cost containment, consolidation, and uniformity of care and want ultimately to reach these same goals in a way that is beneficial to the patient and fosters the development of new technologies to improve the health and lifestyle of every disabled American.
We have outlined three problematic areas of concern with the current LCD and the process that authored the proposed changes:
1. Proposed changes did not involve a panel of Certified or Licensed Orthotists/Prosthetists: CMS proposed changes and RAC audits have been carried out without peer review or proper understanding of the history of the services which are represented by the current coding system. We feel the lack of peer review in these changes is not in accordance with CMS policies and guidelines.
1. Repeatable Outcome Measures are not present to define K level or medical necessity: CMS has offered no repeatable measure for LCMP's to use to document a patient's K level. It has essentially been left up to subjective observation. In order to deem that services are or are not medically necessary CMS must offer a measurement of physical ability that is scientific and repeatable by the patient's therapist, physician, or prosthetist/orthotist.
1. Misunderstanding of Outdated Coding: We understand that CMS must cut unnecessary costs and that the current coding structure needs review. However, the current proposed LCD is insufficient in the provision of care that would be provided for patients. AOPA has laid out these concerns in the Executive Summary and summarized the negative impact to beneficiaries in detail: <URL Redacted>
Proposal:
We humbly submit the following scenario as a solution:
1. We suggest that the draft LCD be rescinded, and code changes be delayed in order to allow Industry leaders, Amputee Advocates, and Prosthetic professionals to participate in a workable solution to reduce cost without negative impact to patient care.
1. We suggest that an advisory board of prosthetic clinicians and industry representatives be established to provide advice to CMS on consolidating coding, and coverage determination. Region C has already established a board of qualified, approved industry leaders, clinicians, and amputee advocates.
1. We suggest that CMS permanently and finally separate Orthotic and Prosthetic devices and their respective L-codes from DME MAC. O&P care (with a very few exceptions) requires a highly trained professional to select and provide the necessary care to the patient. Orthotists and Prosthetists should be recognized as the LCMP that they are. Competitive bidding DME items should be placed under a separate coding structure, as these items require limited training or experience.
We recommend that a CMS Advisory board be formed from the membership of the already established POE group for DME MAC Region C, as the membership is approved and consists of an optimal cross-section of clinicians, industry VIP's, and amputee advocates.
We recommend CMS approve the Advisory Board to be a permanent voice to CMS practices and that the board have the following responsibilities to present a solution for Medicare coding structure now and in the future:
* Provide a proposal within a reasonable time frame for CMS to approve. We suggest 6-12 months
* Achieve projected reductions in CMS prosthetic spending by a set percentage per capita
* Establish set quantifiable measures for defining K level
* Advocate for the patient
* Consolidate Prosthetic coding structures
* Establish updated base coding for each K level to include reimbursement of socket and component add on codes
We believe that the proposal outlined above is the optimal way to reach our mutual goals in cost containment, consolidation, and uniformity of care and would pave the way for appropriate and affordable care for those in need of orthotic and prosthetic care.
We thank you for your time in reviewing this proposal.
Sincerely,
Jeffrey Arnette, CPO, LPO, Member of Region C Provider Outreach & Education Orthotic & Prosthetics Advisory Group
< <URL Redacted>>Michael Arnette, BOCPO, LPO
Brandon Arnette, BOCPO, LPO
All of us have become critically aware of the risk our field and the patients we serve are facing. My staff and I have put together a formal response to the CMS LCD draft. After 20 years of dealing with CMS random audits, appeals, and denials, I have had the privilege of meeting and forging relationships with many of the leaders in the CMS audit and proposal process. After a recent conversation with a close colleague who is a CMS division director, it is my belief that many within the CMS system understand the need for O&P separation from DME.
I believe that now is the time to act with one voice for the industry and our patients with the following recommended proposal for a permanent advisory board of fellow Practitioners, Industry VIP's, and amputee advocacy groups.
We humbly submit the following proposal. We request that you read our full proposal after this summary:
1. We suggest that the draft LCD be rescinded, and code changes be delayed in order to allow Industry leaders, Amputee Advocates, and Prosthetic professionals to participate in a workable solution to reduce cost without negative impact to patient care.
1. We suggest that an advisory board of prosthetic clinicians and industry representatives be established to provide advice to CMS on consolidating coding, and coverage determination. Region C has already established a board of qualified, approved industry leaders, clinicians, and amputee advocates.
1. We suggest that CMS permanently and finally separate Orthotic and Prosthetic devices and their respective L-codes from DME MAC. O&P care (with a very few exceptions) requires a highly trained professional to select and provide the necessary care to the patient. Orthotists and Prosthetists should be recognized as the LCMP that they are. Competitive bidding DME items should be placed under a separate coding structure, as these items require limited training or experience.
Please read the full proposal below.
Sincerely,
Jeff Arnette, CPO, LPO
Member of Region C Provider Outreach & Education Orthotic & Prosthetics Advisory Group< <URL Redacted>>
Progressive Prosthetics www.progressivepo.com
CMS directors
Attn: Stacey Brennan, MD
RE: Proposed LCD DL33787
Dear CMS Directors,
In regards to recent proposed changes in the CMS coverage of orthotics and prosthetics, Orthotists and Prosthetists have come together to unite with one voice for maintained coverage to CMS beneficiaries and reduction in overall cost of prosthetic care. We understand CMS Goals in cost containment, consolidation, and uniformity of care and want ultimately to reach these same goals in a way that is beneficial to the patient and fosters the development of new technologies to improve the health and lifestyle of every disabled American.
We have outlined three problematic areas of concern with the current LCD and the process that authored the proposed changes:
1. Proposed changes did not involve a panel of Certified or Licensed Orthotists/Prosthetists: CMS proposed changes and RAC audits have been carried out without peer review or proper understanding of the history of the services which are represented by the current coding system. We feel the lack of peer review in these changes is not in accordance with CMS policies and guidelines.
1. Repeatable Outcome Measures are not present to define K level or medical necessity: CMS has offered no repeatable measure for LCMP's to use to document a patient's K level. It has essentially been left up to subjective observation. In order to deem that services are or are not medically necessary CMS must offer a measurement of physical ability that is scientific and repeatable by the patient's therapist, physician, or prosthetist/orthotist.
1. Misunderstanding of Outdated Coding: We understand that CMS must cut unnecessary costs and that the current coding structure needs review. However, the current proposed LCD is insufficient in the provision of care that would be provided for patients. AOPA has laid out these concerns in the Executive Summary and summarized the negative impact to beneficiaries in detail: <URL Redacted>
Proposal:
We humbly submit the following scenario as a solution:
1. We suggest that the draft LCD be rescinded, and code changes be delayed in order to allow Industry leaders, Amputee Advocates, and Prosthetic professionals to participate in a workable solution to reduce cost without negative impact to patient care.
1. We suggest that an advisory board of prosthetic clinicians and industry representatives be established to provide advice to CMS on consolidating coding, and coverage determination. Region C has already established a board of qualified, approved industry leaders, clinicians, and amputee advocates.
1. We suggest that CMS permanently and finally separate Orthotic and Prosthetic devices and their respective L-codes from DME MAC. O&P care (with a very few exceptions) requires a highly trained professional to select and provide the necessary care to the patient. Orthotists and Prosthetists should be recognized as the LCMP that they are. Competitive bidding DME items should be placed under a separate coding structure, as these items require limited training or experience.
We recommend that a CMS Advisory board be formed from the membership of the already established POE group for DME MAC Region C, as the membership is approved and consists of an optimal cross-section of clinicians, industry VIP's, and amputee advocates.
We recommend CMS approve the Advisory Board to be a permanent voice to CMS practices and that the board have the following responsibilities to present a solution for Medicare coding structure now and in the future:
* Provide a proposal within a reasonable time frame for CMS to approve. We suggest 6-12 months
* Achieve projected reductions in CMS prosthetic spending by a set percentage per capita
* Establish set quantifiable measures for defining K level
* Advocate for the patient
* Consolidate Prosthetic coding structures
* Establish updated base coding for each K level to include reimbursement of socket and component add on codes
We believe that the proposal outlined above is the optimal way to reach our mutual goals in cost containment, consolidation, and uniformity of care and would pave the way for appropriate and affordable care for those in need of orthotic and prosthetic care.
We thank you for your time in reviewing this proposal.
Sincerely,
Jeffrey Arnette, CPO, LPO, Member of Region C Provider Outreach & Education Orthotic & Prosthetics Advisory Group
< <URL Redacted>>Michael Arnette, BOCPO, LPO
Brandon Arnette, BOCPO, LPO
Citation
Jeff Arnette, “Our response to proposed prosthetic LCD changes,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 2, 2024, https://library.drfop.org/items/show/237607.
