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David McGill Blogger

Prosthetist Notes Legislation Passed Into Law

Posted by David McGill | February 09, 2018

In the early morning hours of February 9th, Congress passed legislation (then signed into law by President Trump) that includes the following language:

For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual's medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).

What does this mean for you?

First, passage of this law ensures for the first time that whenever the DME MACs, RAC, ZPIC or other entity review your claims, your clinical notes can be considered by them as part of the official medical record justifying approval/payment. This is a significant win for O&P clinicians, as inclusion of their notes in this analytical process insures that the voice of the individual with the most clinical expertise and training in orthotics and prosthetics gets taken into account and weighed appropriately as part of the claims process. Historically, Medicare could dismiss orthotists'/prosthetists' notes from consideration when evaluating medical necessity. That will no longer be the case moving forward.

Second, we must also emphasize that passage of this law does not mean that the DME MACs and other contractors 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. Similarly, where the LCD's explicitly require physician documentation - for example, see the language in the LCD for custom-fabricated knee braces - this new law does not eliminate that requirement. Please do not make the mistake of ignoring these facts moving forward, as it will give the DME MACs and other contractors a basis to deny your claims.

Third, this new legislative language represents an important step forward not only practically from a claims perspective, but from the broader viewpoint of reinforcing the expertise of O&P clinicians. These professionals have argued for years that their notes should have just as much weight as those of other clinicians involved in the treatment of amputees and individuals with mobility impairments.

Finally, passage of this law may have a positive impact on the individuals you treat. Knowing that their notes must now be considered as part of the medical record, orthotists and prosthetists may be more willing to quickly deliver medically necessary O&P devices, especially in emergent/emergency situations, than in the past.

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