Podiatry Coding & Billing Alert

Hint: Grasp the importance of the physician's assessment.

Knowing how to report ankle-foot orthoses (AFOs) and knee-ankle-foot orthoses (KAFOs) can be challenging, but you don't have to make the same mistakes others have made. In "Avoid Common CERT Errors for Orthotics to Fortify Your Future Claims" in the Volume 10, No. 3 issue of Podiatry Coding and Billing Alert, you learned the top CERT errors to avoid.

Now, check out the following FAQs regarding orthotic claims, offered in the webinar "An Overview of CERT Errors for Orthotics," which the DME CERT Outreach and Education Task Force presented.

FAQ 1: Who Can Provide Verbal and Written Dispensing Orders for Orthotics?

Answer: The following people are authorized to order orthotics, according to Michael Hanna, MPA, CDME, provider outreach and education consultant at CGS-DME MAC Jurisdiction C in Nashville, Tennessee:

• A treating physician who must be either an MD or DO. In certain circumstances, the treating physician could be a DPM for certain durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) items, Hanna adds. This largely depends on state regulations.
• A Nurse Practitioner (NP)
• A Clinical Nurse Specialist (CNS)
• A Physician Assistant (PA).

"Any of these practitioners may provide the dispensing order and write and sign the detailed written order, if the requirements are met and they are enrolled in PECOS [provider enrollment, chain, and ownership system] with an active NPI [national provider identified]," Hanna says.

FAQ 2: A Detailed Written Order Must Include What Items?

Answer: For detailed written orders, you need the following information, according to Hanna:

• A detailed description of the item. Some examples of acceptable descriptions include a HCPCS code description and the manufacturer's name, make, and model number of the orthotic.
• The patient's name
• The prescribing physician's name
• The date of the order
• Detailed descriptions of any separately billed options or accessories you are billing to Medicare
• The prescribing physician's signature and date.

FAQ 3: What's the Importance of the Physician's Assessment to the Medical Record?

Answer: "The physician's assessment information is an important aspect of the medical record specifically related to both the patient's physical and cognitive abilities," says Michelle Wullstein, provider outreach and education consultant at Noridian Healthcare Solutions, LLC.

This assessment can include the following items, according to Wullstein:

• The history of the patient's present condition - How long has the condition progressed? How long has the condition been an issue? What types of treatments have been done in the past to try to address that condition?
• Any symptoms the patient has related to ambulation or dexterity - What is impacting the patient's ability to ambulate?
• The expected cause of the patient's symptoms - What's the diagnosis?
• Co-morbidities related to the patient's ambulation.
• If the patient is using an assistant device for his ambulation - Is he using crutches, a cane, or walker?
• Description of activities of daily living - How is he able to get around his home? How will the use of this type of a brace benefit him in relation to that?  

"Those are all important aspects that we look for in the review of the medical record to help justify the need for an item," Wullstein says.

FAQ 4: How Does the Physician's Assessment Relate to the Physical Exam?

Answer: When you are looking at the physician's assessment regarding the physical exam, it's vital that there is objective information, according to Wullstein.

"Just indicating that the patient has pain isn't always going to be enough," she says. "There has to be more objective information to support that."

Other important information in the physician's assessment includes the following:

• The patient's height and weight. "There are some orthoses that are specific to beneficiaries who weigh a little bit more," Wullstein adds. "Or depending on their height, they might be able to only use a certain type of orthosis."
• Cardiopulmonary examination.
• Musculoskeletal examination - the patient's arm and leg strength and range of motion.
• Neurological examination - "This is very important, especially for those lower limb orthoses - the patient's gait, balance, and coordination," Wullstein adds. "That all comes back to the beneficiary's ability to ambulate and how it could be impacted by the use of a particular type of orthosis."