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David McGill Blogger

The Error of Your Ways

Posted by David McGill | October 26, 2012

MAC Region A posted a CERT Error Rate publication to its website last Friday. Like all such publications, this one is designed to “assist suppliers in understanding the CERT review process, and to become familiar with the type of medical records requested.”

The key findings for 2 prosthetic claims discussed in the CERT Review:

Claim #1

  • The prosthetist’s evaluation “identifies the functional level at K3, but the evaluation does not document how K3 was arrived at.”
  • “There is a strength assessment but lacks documentation [sic] of ambulation capability and or potential ambulation capability.”
  • “[D]ocuments only general statements of the fit and function with no assessment of ambulation, balance, etc. that would support the K3 functional level and no documentation of how the beneficiary ambulates with the new prosthesis[.]”
  • Missing documentation in the treating physician’s clinical records regarding the patient’s K3 status.

Claim #2

  • Prosthetist’s final fitting and deliver note states, “socket fit very well” however no documentation of gait with new prosthesis.
  • “No notation of intent or need to replace prosthesis.
  • Missing “[t]reating physician’s clinical documentation supporting the medical necessity of replacing the Prosthesis [sic] prior to ordering the replacement[.]”
  • Missing “CPO’s evaluation of gait w/ new prosthesis at delivery supporting functional ability.”

What Does This Mean For You?

Taken together, the claims discussed in the CERT publication highlight three key things you need to address.

First, you need to be sensitive to K level documentation, a point we have discussed this in the past. (See our “Running the Functional Level Gauntlet” post, August 24, 2012). The MACs no longer blindly accept a prosthetist’s notes claiming K3 or K4 status. It’s clear they want something more. Your records must include a detailed description of why your patient is K#. “Because I said so” doesn’t cut it.

One way to buttress your K-level claim – and likely the most effective should you ever have to appeal a denial – is video of your patient. Given the ease with which you can now take high-quality video – iPhone with hi-def video recording, anyone? – why wouldn’t you take 5 minutes to shoot your patients walking every time they visit your facility?

Second, general statements of fit and function – “Patient donned prosthesis and it fit well”; “patient walked with no complaints and satisfied with fit” – will not withstand MAC scrutiny. A note based on non-specific statements should instead be broken down into a detailed description. For example:

“Patient donned new socket; no issues donning and no complaints of discomfort when static in prosthesis; patient walked for 25 minutes in facility without complaint; instructed patient to walk at extremely slow, self-selected, and faster than self-selected walking speeds; patient walked at all speeds without difficulty (video taken); evaluated gait and alignment; externally rotated prosthetic foot slightly after observing internal orientation unrelated to how socket donned by patient; following 25 minutes of walking, patient doffed socket and residual limb examined; no signs of breakdown, irritation, redness, or other indicia of compromised fit. (video taken)”

Third, ensuring that physician documentation corroborates your records remains a central challenge and necessity. We strongly recommend not delivering any prosthesis or a part thereof to a Medicare beneficiary until you confirm that the physician’s record adequately supports yours. You do this by establishing a relationship with the physician so that she understands your patient’s documentation needs. In addition, ask your patient to help. The Amputee Coalition has even developed a letter to assist you in that effort.


The MACs are clearly signaling to the O&P community what it is that they are looking at and for. The facilities best able to bring their processes in line with these requirements will have a huge competitive advantage over those that throw their hands up in despair and ask, “Why can’t it be like it was in the good old days?” The good old days are gone. You have to adapt to survive.

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