Podiatry Coding & Billing Alert

Remember: If it's not documented, then it hasn't been done.

CMS manages the Comprehensive Error Rate Testing (CERT) program, which measures improper payments in the Medicare Fee-for-Service (FFS) program. Recently, the DME CERT Outreach and Education Task Force presented a webinar of the top CERT errors for orthotics, including ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs).

Read on to avoid making these costly mistakes in your podiatry practice and to brush up on general rules about Medicare documentation requirements.

Steer Clear of These Top AFO and KAFO Errors

In the webinar, Michael Hanna, MPA, CDME, provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee, identified the following CERT lower limb orthotics errors:

The claim was missing the necessary medical documentation to support the medical necessity of the patient's need for a custom fabricated AFO versus a prefabricated orthosis device.

There wasn't sufficient medical documentation and medical necessity to support the patient's need for an orthosis for the weakness and deformity of his foot and ankle. This includes not having sufficient documentation detailing the patient's need for stabilization from the orthosis and the potential benefits he could receive functionally from the item.

The detailed written order was either not provided, was missing sufficient detail, or was missing the patient's signature.

There wasn't enough medical documentation to support that a qualified individual performed substantial modification to the prefabricated item.

The proof of delivery (POD) for the billed item was either missing, did not include enough detail, or did not include the patient's or designee's signature.

There wasn't a detailed description outlining the need for substantial modification at the patient's orthosis fitting to give him an individualized fit beyond just the minimal self-adjustment.

"I can sum up all the errors with AFOs/KAFOs with the word 'missing,' Hanna said. "Either missing clinical documentation for the medical record or possibly about the need for the item or the need for a custom fabricated versus prefabricated."

From a delivery ticket and detailed written order standpoint, either that document was not provided as requested by the CERT contractor, Hanna added, or maybe it was missing details or was not signed.

Remember General Medicare Documentation Rules

In the webinar, Michelle Wullstein, provider outreach and education consultantat Noridian Healthcare Solutions, LLC, offered some general Medicare documentation rules to keep in mind as you handle your orthotics claims:

Rule 1: You must make sure you have access to the medical documentation that supports the medical need for any items the podiatrist provides.

Because of the nature of these orthotic policies, they don't fall within the face-to-face requirements, Affordable Care Act, etc., where there has to be the in-person visit prior to ordering the item, Wullstein said. However, there still needs to be an established need before the item is provided.

"You need to make sure you have access to those records," Wullstein added. "You don't necessarily have to obtain them prior to dispensing the item, but you do need to make sure that they exist. Whether or not you obtain them prior to delivery is a business practice decision."

Rule 2: Although the medical records most commonly come from the physician who orders the item, other types of records can help support that documentation, as well.

This includes hospital records, nursing home records, home health agency records, records from other healthcare professionals, and test reports, Wullstein said. These are great sources of information that will help support the need for the item.

Rule 3: If it's not in the medical documentation, then it hasn't been done.

"I cannot stress this enough when it comes to not only the physician's records, but also your own practitioner records for those of you who have orthotists and prosthetists on staff," Wullstein said.

Although the records of the orthotists and prosthetists cannot stand alone for medical necessity, they are important regarding the need for the items - in terms of the types of components and necessary add-ons, Wullstein added. "So, it's important that their records be detailed, as well."

The reviewers for the DME MACS can't make assumptions about what occurred during patient encounters. They can't assume what kind of treatment the patient has already gone through or will go through in the future, according to Wullstein. So, it must be documented.

"That's something we see a lot, too, with the prefabricated orthoses and determining between theoff-the shelfand the custom-fit items," Wullstein said. "When it comes to those substantial modifications, it's important that the documentation be specific in regards to what those modifications are."

Rule 4: Make sure the medical documentation is available upon request and kept in the supplier's file for at least seven years.