PRESENTED BY:

Aaron Sorensen, MBA, CPO, LPO

O and P Billing Solutions, Inc.

General Medicare Coverage Guideline

General Lower Extremity Prosthetic Policy ◦Coverage Indications and Limitations

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider”

It is expected that the patient's medical records will reflect the need for the care provided. The patient's medical records include the physician's office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports.

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.

Templates and forms, including CMS Certificates of Medical Necessity, are subject to corroboration with information in the medical record ◦ New Physician Template coming ◦ http://www.cms.gov/Research-Statistics-Data-and-

Systems/Computer-Data-and-Systems/Electronic-Clinical-Templates/Lower-Limb-Prosthesis-Electronic-Clinical-Template.html

Information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs.

The medical record is not limited to physician’s office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc.

Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary

An order for each item billed must be signed and dated by the prescribing physician, kept on file by the supplier, and made available upon request. ◦ Items billed before a

signed and dated order has been received by the supplier must be submitted with an EY modifier added to each affected HCPCS code.

Signature Log ◦ Lists printed or typed name(s) and

signatures of authors of medical records and orders

◦ Should also include the authors credentials

Signature attestation statement ◦ Used to authenticate illegible or

missing signatures on orders and medical records

◦ Requirements include date the attestation was generated and the documents and their date(s) that are included for the attestation

◦ Signature of the person attesting to the records and date attestation signed

◦ http://www.cgsmedicare.com/jc/index.html# then click on “FORMS”

Proof of delivery documentation must be available to the Medicare contractor on request.

All services that do not have appropriate proof of delivery from the supplier will be denied and overpayments will be requested.

A lower limb prosthesis is covered when the patient:

◦ Will reach or maintain a defined functional state within a reasonable period of time; and

◦ Is motivated to ambulate

A determination of the medical necessity for certain components/additions to the prosthesis is based on the patient's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to: ◦ The patient's past history

(including prior prosthetic use if applicable); and

◦ The patient's current condition including the status of the residual limb and the nature of other medical problems

Clinical assessments of rehabilitation potential must be based on the following classification levels:

Level 0: Does not have the ability or potential to ambulate or transfer safely with or without assistance Level 1: Has the ability or potential to use a prosthesis for transfers or ambulation on level surfaces at fixed cadence. Typical of the limited and unlimited household ambulator. Level 2: Has the ability or potential for ambulation with the ability to traverse low level environmental barriers such as curbs, stairs or uneven surfaces. Typical of the limited community ambulator.

Level 3: Has the ability or potential for ambulation with variable cadence. Typical of the community ambulator who has the ability to traverse most environmental barriers and may have vocational, therapeutic, or exercise activity that demands prosthetic utilization beyond simple locomotion. Level 4: Has the ability or potential for prosthetic ambulation that exceeds basic ambulation skills, exhibiting high impact, stress, or energy levels. Typical of the prosthetic demands of the child, active adult, or athlete.

The records must document the patient's current functional capabilities and his/her expected functional potential, including an explanation for the difference, if that is the case. ◦ It is recognized, within the functional classification hierarchy,

that bilateral amputees often cannot be strictly bound by functional level classifications.

Medicare considers every amputee K2 and medical documentation is required to support ALL functional levels.

Temporary and early fitting prostheses have a finer level of exceptions in addition to functional levels

Face-to-Face encounters for DME July 1. All Rx good for 1 yr maximum; trending to face-to-face

in O and P.

Aaron Sorensen, CPO, LPO, President OPBS asorensen@rhs-tn.com

Ph. 877-907-4180

Rob Cripe, VP Global Marketing rcripe@freedom-innovations.com Ph. 949-544-7916

Freedom Innovations thanks you for your continued support and hopes this series of webinars helps you navigate the tumultuous environment of serving MEDICARE PATIENTS.

Please provide feedback to your Freedom sales representative of future topics to cover and if you find these webinars helpful.

Next webinar: August 2 Topic: Building

Relationships with Physicians