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David McGill Blogger

Clarification from MAC Region B: "Hold on a sec!"

Posted by David McGill | January 30, 2013

On December 17 we posted regarding MAC Region B's guidance regarding physician documentation. In a nutshell, we noted that based upon the transcript from November's "Ask the Contractor Teleconference," Region B had taken the position that the prescribing physician's annotation of both specialists' and prosthetists' patient notes would convert those notes into part of the prescribing physician's medical record.

Thanks to information provided by one of our Region B readers, we have learned that the MAC updated its summary of the teleconference just over a week ago. Included in that update was the following clarification regarding the annotation concept:

Suppliers are reminded per the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual … 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. [emphasis added]

Review of the relevant section of the Internet-Only Manual leads us here:

[A] supplier prepared statement … [does not] by itself provide[ ] sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. [emphasis added]

Chapter 5, Section 5.7

What does this mean for you?

  1. MAC Region B has effectively reversed course on the guidance provided by its representative during the November teleconference. Based upon this update, we no longer believe that it is appropriate to have a physician annotate a prosthetist's records. If you nevertheless continue, MAC Region B will take the position that the prosthetist's annotated note is not part of the physician's medical record!
  2. As a result, we believe the new "best practice" is the same as the old one (i.e., the one that applied before publication of the original MAC transcript): the physician's notes must contain appropriate documentation separate and apart from the prosthetist's records. We do not recommend delivering a prosthetic item to a Medicare beneficiary until you have confirmed that the physician's records include this information.
  3. The updated guidance does not affect the ability of the prescribing physician to annotate another specialist's medical records. In other words, if the prescribing physician annotates a PM&R doctor's report/records, that would continue to be appropriate and would make the PM&R doctor's notes part of the prescribing physician's medical record. The limitation on annotation applies only to DMEPOS suppliers.
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