Physician Documentation Requirements

What You Need to Know

1. Prostheses: What Medicare Requires Physicians to Document

a) The patient's functional capabilities, both before and after amputation.

NOTE: The Dear Physician letter states that "simply stating the functional level in your patient's record is not sufficient."

b) An assessment of the patient's physical and cognitive capabilities.

• Symptoms limiting ambulation or dexterity and the diagnoses causing those symptoms.
• Comorbidities limiting the patient's mobility or affecting the use of a new prosthesis.
• Any ambulatory aids the patient uses.
• The patient's activities of daily living.

c) A physical exam relevant to any functional deficits:

• Weight, height, weight gain/loss.
• Cardiopulmonary examination.
• Musculoskeletal examination (arm/leg strength and range of motion).
• Neurological examination (gait, balance, coordination).

 2. Knee Orthoses: What Medicare Requires Physicians to Document

Specific clinical findings based on the type of brace prescribed.

A.  Braces described by L1810, L1812, L1820: Knee weakness or deformity requiring stabilization.

B.  Braces described by L1832, L1833, L1843, L1844, L1845, L1846, L1851, L1852: Either (a) recent injury to or surgery on the patient's knee(s), or (b) knee instability in an ambulatory patient.

NOTE: To satisfy B.1.ii, the physician must objectively document joint laxity. In addition, the physician must assign one of the Group 4 ICD-10-CM codes to support medical necessity.

C.  Braces described by L1831, L1836: Both (a) flexion or extension knee contracture with movement on passive ROM testing of at least 10 degrees, and (b) a Group 1 ICD-10-CM code.

D.  Braces described by L1830, L1834: Both (a) evidence of recent injury to or surgery on the patient's knee(s), and (b) either a Group 2 or 4 ICD-10-CM code.

E.  Braces described by L1850: All of the following: (a) patient is ambulatory with knee instability from genu recurvatum - hyperextended knee, congenital or acquired, (b) examination of the patient with objective description of joint laxity; and c) a Group 5 ICD-10-CM code.

F.   All custom-fabricated knee braces (L1834, L1840, L1844, L1846, L1860): In addition to any of the applicable requirements listed in i-v, the physician must medically describe why the patient needs a custom brace rather than a prefabricated one. Possible reasons include but are not limited to deformity of the leg/knee, size of the patient's thigh or calf, and lack of muscle mass upon which to suspend the orthosis.

NOTE: Medicare will not approve knee brace claims based on (a) a physician's documentation of pain only, or (b) a subjective description of joint instability.

What this Means for You

If you are an O&P seeking corroborating information from a physician, make sure doctors and their staff know that these are Medicare's requirements. Share the Dear Physician letter with them and explore ways to coordinate care on these issues for the benefit of your mutual patient.

If you are a physician providing a brace to your own patients ancillary to the core care you provide, review the Dear Physician letter to make sure your documentation satisfies these requirements. If you work as an operational leader or claims specialist in a physician's office and your doctors struggle to comply with or resist creating notes complying with these requirements, use the Dear Physician letter to educate them.

The Dear Physician letters for each DME MAC region are identical. While you can access them from any DME MAC region's website, you can click on this link to Region C's Dear Physician webpage for easy access. And as noted above, most knee orthoses require physicians to assign an ICD-10-CM code to support medical necessity. You can find a full listing of those codes in the Knee Orthoses Policy Article.