In early May, the DME MAC Medical Directors announced that they were ‘retiring’ the August 2011 Dear Physician letter on lower limb prostheses. CMS has just issued instructions for immediate implementation of the provisions requiring the recognition of orthotist and prosthetist clinical documentation as part of the medical record. A huge win for the O&P profession!
The Dear Physician letter for prostheses fundamentally changed how Medicare claims for artificial limbs were processed. Prior to the 2011 Prosthetic Dear Physician letter, practitioner notes were generally accepted as being a valuable part of the patient’s medical documentation.
The Dear Physician letter made it clear that for Medicare purposes, “it is the treating physician’s records, not those of the prosthetist’s, which are used to justify payment.” This statement and the overall tone of the Dear Physician letter, lead to years of frustration where the clinical notes of qualified, educated, certified and licensed prosthetists, were simply ignored during the claim review process. This exclusion of valuable clinical information lead to higher claim denial rates and unacceptable delays in the appeal process.
With the February 2018 passage of legislation that now requires documentation created by orthotists and prosthetists to be considered part of the patient’s medical record for medical review purposes, the Dear Physician letter was no longer consistent with the law.
The following excerpt from a recent letter from Alec Alexander, CMS’ Director of Program Integrity, indicates that CMS “has issued instruction to the Durable Medical equipment (DME) Medicare Administrative Contractors (MAC) to implement Section 50402 of the Bipartisan Budget Act of 2018 immediately.”
Mr. Alexander’s letter is a clear affirmation of CMS’ commitment to recognize immediate implementation of the new statutory provisions in Section 50402, accepting the orthotist and prosthetist clinical notes as part of the individual’s medical record as to “determining the reasonableness and medical necessity of orthotics and prosthetics”, for example, the patient’s functional level, identification of the need for repairs and identifying appropriate components based on the functional category included in the physician’s approved detailed written order.