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David McGill Blogger

New Prosthetic Dear Physician Letter Released

Posted by David McGill | November 15, 2018

Earlier this week the DME MACs published a new version of the Dear Physician letter. We have compared this document to the old one dated August 11, 2011, to highlight key differences between them. Here are the 5 changes you need to know:

  1. The new letter explicitly references the law passed earlier this year providing that "documentation created by an orthotist or prosthetist shall be considered part of the individual's medical record[.]" 

  2. The new letter also states that "[t]he O&P supplier's notes are but part of the whole medical record and are considered in the context of documentation made by you [the physician] and other healthcare practitioners to provide additional details to demonstrate that the prosthetic arm, leg or orthotic billed to Medicare was reasonable and necessary." [emphasis added]

  3. It further provides that "payment may not be provided solely based on O&P documentation, and in the absence of physician/practitioner documentation, the DME MACs may deny payment for the orthotic or prosthetic."

  4. The new letter additionally contains the following language: "Simply stating the functional level in your patient's record is not sufficient."

  5. It also features an entirely new section focused on orthotics, instructing physicians to refer to the specific coverage requirements for different bracing products in the applicable orthotic LCD's.

What does this mean for you?

We believe there are three key takeaways from the new Dear Physician letter. First, the formal acknowledgment that orthotists' and prosthetists' notes are part of the medical record is a positive development. It enhances clinicians' ability to ensure that their documentation gets considered during the claims review process.

However, the DME MACs have simultaneously doubled down on the importance of detail in the physician's corroborating records. This is best illustrated in their conclusion that a physician who simply records the patient's functional level, without more, has failed to adequately support that functional level determination. 

Lastly, the combination of the first two conclusions above supports the conclusion we reached and published in Ossur R&R in February when the orthotists' and prosthetists' notes law was first passed:

[P]assage of this law does not mean that the DME MACs and other contracts are prohibited from examining the physician's records and considering inconsistencies between their clinical conclusions and yours. If the clinical picture you paint of the patient is at odds with the physician's, you should expect the reviewer to request additional information and, if the apparent conflict is not resolved, deny the claim. In other words, we believe it remains a best practice to continue to ensure that the physician's documentation is consistent with yours." [emphasis added]

In short, continue to get corroborating information from the physicians you work with. Make sure that their functional level determinations contain details beyond the simple K-level designation. And do not assume that the fact that your notes are now part of the medical record somehow insulates you from having to comply with the guidance in the preceding sentences. We have talked about the need for corroborating information since Ossur R&R's inception in 2012 - that need still exists today. If you are diligent about obtaining this information from the physicians you work with, you will be compliant with the standards set forth in the newly published Dear Physician letter and successful with your Medicare claims.

Össur R&R

The Source for O&P Reimbursement & Regulatory News & Analysis

If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at [email protected]