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David McGill Blogger

Physician Documentation: One Region’s Guidance

Posted by David McGill | December 17, 2012

DME MAC Region B has made the transcript for last month’s “Ask the Contractor Teleconference” available. Based on our review of that transcript, we want to emphasize two aspects of what the MAC said about physician documentation.

First, Region B confirmed that a letter from a specialist physician can become part of the prescribing physician’s medical record. The requirements are as follows:

a. The prescribing physician needs to sign the specialist’s letter;
b. The prescribing physician needs to date the specialist’s letter; and
c. The prescribing physician needs to annotate if they agree or disagree with what’s in the letter.

If prescribing physicians complete each of these three steps, then the specialist’s letter becomes part of their medical records as far as the MAC is concerned.

Second, Region B also responded to a question about documenting K levels appropriately. The implications are significant, and we quote the MAC representative’s comments in their entirety:

When it’s coming to the functioning level, we are needing exact documentation that’s pointing directly to the functional level that you’re billing for.

What we see happening a lot is that, based off the functioning level of the beneficiary, they’re a K2, but they’re being supplied for services for a K3, and that’s not sufficient information.

What we also hear a lot is that physician records don’t have the information, but the [ ] prosthetist’s records have that information. So what the prosthetist should be doing is contacting the physician, by sending their records over to the physician, so the physician can review that documentation that has been made by the prosthetist, and then that way, the physician (go) [sic] ahead and sign and date that report, along with annotating if they agree or disagree, so that information does become a part of the record. [Emphasis added]

* * *

[W]e can’t take [ ] your word in regards to your medical record only, because you have the financial relationship in order to get payment from Medicare. If that [ ] information comes from the physician, they’re going to be able to put what they want or what they don’t want, or what they’re not liking about your record.

Together, what do these two things mean for you?

1. Sometimes, key findings relevant to support your claim for reimbursement may exist in a letter from a specialist, not in the prescribing physician’s notes. When you’re confirming the prescribing physician’s documentation before delivering an item to a Medicare beneficiary, make sure (1) to ask if there are any notes/letters from a specialist about your patient, and (2) that the prescribing physician has signed, dated, and noted their agreement/disagreement with the specialist’s finding.

2. Based on the response to the K-level question from MAC Region B, the same requirements that apply to specialty physicians’ notes becoming part of the prescribing doctor’s medical record also apply to prosthetist’s notes. In other words, if a doctor signs, dates, and annotates the patient notes forwarded by the prosthetist, those notes would now be considered part of the doctor’s medical record, not “ancillary” to it.

We know that many prosthetists have implemented measures that are substantially more involved than what’s described in the preceding paragraph in an effort to ensure appropriate physician documentation. But, if MAC Region B is taken at its word, prosthetists can simply send their notes to the prescribing physician, include their K-level findings, and so long as the prescribing MD signs, dates, and annotates the prosthetist’s notes, that will serve as sufficient documentation.

NOTE #1: A prosthetist’s K-level documentation must include information about (1) the beneficiary’s medical and prior functional status if it’s the beneficiary’s first-ever prosthetic claim, (2) whether the beneficiary will reach or maintain a defined functional state within a reasonable period of time, and (3) whether the beneficiary is motivated to ambulate.

NOTE #2: We would recommend that suppliers in other Medicare Regions confirm this information with their specific MAC before choosing to follow Region B’s publicly-stated guidance.

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