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EXECUTIVE DIRECTOR
Brian Lagana
PFA Executive Director
[email protected]
Medicare Documentation Requirements –
Business as the New Normal?
S
ince Medicare’s implementation of enhanced
documentation requirements across most of its
benefit categories, including the Therapeutic
Shoes for Persons with Diabetes benefit, and a
subsequent increase in audits of providers and
suppliers records, PFA has been asked many times over why
and what can be done about it.
The bottom line on the increased documentation
requirements and increased scrutiny from Medicare’s
contracted auditors is that it really is all about the bottom
line. Medicare, by way of Congress, is seeking to reduce
its outlay for claims as much as possible by utilizing the
regulatory tools available to it. Essentially, Medicare – with a
budget of about $1 trillion this fiscal year - is broke, and the
fix may be to deny as many claims across the entire Medicare
program as possible. (Medicare’s foray into competitive
bidding is another way to reduce spending but still fulfill
its Congressional mandate to service its beneficiaries – the
recently announced competitive bid price for mail order
diabetic supplies is a perfect example.) Hence, the enhanced
documentation requirements to ensure medical necessity for
whatever is being provided to the patient by a provider or
supplier, and the aggressive auditing to ensure that all of the
required documentation has been captured and is available
for review.
What can you, as a pedorthist/supplier, do to ensure that you
have as few claims denials as possible?
Know first off that physicians that refer Medicare
beneficiaries to you are legally required under the Social
Security Act to provide you with the documentation necessary
to ensure that the claim that you submit for servicing their
referred patient is provided to you. Providing you with this
documentation is not a violation of the HIPPA privacy rule.
Next, ensure that you have all of the required pieces of
documentation required by Medicare. A documentation
checklist for the Therapeutic Shoes for Diabetes benefit
has been created by the Centers for Medicare and Medicaid
Services (CMS), and is available through their website at
www.cms.gov, or the PFA website in the Information for
DMEPOS Suppliers section at www.pedorthics.org. I have
heard from members who go so far as to document the
devices provided to the patients by making photographs a part
of the patient record.
We have been asked if it is possible for other practitioner
types to sign the Statement of Certifying Physician attesting
8
Pedorthic Footcare Association www.pedorthics.org
to the patient’s diabetic condition and the medical necessity
for shoes, inserts and modifications. Unfortunately, the
requirement that the attestation be signed by an MD or a
DO was written into the law that Congress passed in the late
1980s that eventually became the regulation that created the
TSD. It would take an act of Congress to change this (and
many of the other requirements that you find in the Local
Coverage Determinations and Policy Articles for Medicare
benefits).
Questions about allowing the pedorthists clinical notes to
be considered by CMS as part of the overall patient record
when determining medical necessity have also been raised.
Essentially, CMS looks at pedorthists (and others) who
provide lower extremity modalities, including therapeutic
shoes, inserts and modifications, as suppliers, and not
clinicians. Their thought on this perception is that suppliers
have an inherent financial interest in the claim because
they receive reimbursement for the items that they dispense
to the patient, and thus a conflict of interest in being able
to self-document in support of medical necessity (not solely
determining medical necessity).
Some of the pedorthists that are most successful in obtaining
the necessary documentation and submitting the cleanest
claims to Medicare are those that subscribe to the team
approach with their referral sources and patients. Building a
strong rapport with your referral sources and their staff can go
a long way toward maintaining open lines of communications
about what you need to be able to service their patients, and
educating your referral sources about the importance of their
cooperation to you and their patient. Bringing the patient/
beneficiary into the loop and letting them know the critical
role that they play as a stakeholder in assisting you to ensure
that their doctor provides you what is necessary is important
as well, given that they are the ultimate beneficiary of a
cooperative relationship between their physician and their
DMEPOS supplier.
Pedorthists, along with everyone else in the healthcare
industry, are burdened by a tremendous load of paperwork.
CMS is striving to educate everyone involved in the
continuum of care of Medicare beneficiaries as to their roles
and responsibilities. However, a little additional outreach
on everyone’s part can go a long way towards making the
healthcare paperwork monster more manageable. At the end
of the day, the patient/beneficiary will be the winner – or the
loser – if Medicare continues to hemorrhage providers and
suppliers.