The Medical Record: What Is It?

The Issue:

Medicare requires that the beneficiary’s medical record “contain sufficient documentation of the beneficiary’s medical condition to substantiate the necessity” of the prosthetic or bracing (orthotic) device. But what exactly is the “medical record?”

What You Need to Know:

Medicare defines much of what the medical record is by exclusion – in other words, stating in detail what it is not. None of the following items are part of the medical record.

1. A signed practitioner’s order (i.e., prescription/Standard Written Order);

2. A signed supplier-prepared statement;

3. A signed practitioner’s attestation (often known as a letter of medical necessity).

On the other hand, physician and licensed/certified medical professionals’ templates used to document and gather clinical information during patient visits are part of the medical record. However, check-box templates and similar templates that don’t offer the possibility of unique narrative notes may not be sufficient to satisfy coverage and coding requirements. Medical records also include hospital, nursing home, and home health agency records, as well as records from other professionals. Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not, by themselves, sufficient for determining whether a device is reasonable and necessary.

What This Means for You:

Because both O&P’s and DME companies have a financial interest in the outcome of claims involving the items/services they deliver, their notes, standing alone, are insufficient to demonstrate medical necessity based on Medicare’s regulations. This means, they must obtain corroborating information from a physician or other licensed/certified medical professional. In addition, records from hospitals, nursing homes, home health agencies etc. can serve as valid corroboration.

Importantly though corroborating information must actually corroborate the supplier’s findings. While this would appear to be a truism, there are times where a supplier’s documentation is not supported by the medical record. You must therefore be mindful of the fact that the DME MACs and auditing contractors can (and often do) review information in the medical record from other health care providers. If that documentation paints a different picture than what you have recorded, there is a high likelihood that the claim will be denied or that payment will be clawed back in an audit.

Accordingly, both detailed documentation and effective coordination with the physician or treating practitioner* is the best practice to ensure submission of a successful claim and, equally important, the ability to withstand audits if they do arise.

* “Treating practitioner” refers to a physician, physician assistant, nurse practitioner, or clinical nurse specialist.