Documentation Requirements for LL Prosthetics

Transcription

1 Ottbck has relied upn the CMS guidance and recmmendatins set frth in this dcument s reference sectin belw. Medicare s Criteria in a Nutshell Medical necessity fr prsthetic cmpnents r additins t the prsthesis is based n: 1. The patient s past histry [activities], 2. The patient s current cnditin [residual limb and any medical cnditins that might affect patient s ability t use the new prsthesis], and 3. Desire t ambulate. [desire t use the new prsthesis and get back t thse previus activities] A lwer limb prsthesis is cvered when: 4. Prescribed by a physician 5. The member will reach r maintain a defined functinal state (K-Level) within a reasnable perid f time, and 6. The member is mtivated t ambulate Medicare requires that all 6 criteria be dcumented in the physician s medical recrd. Fllwing is a guide: Ntes: Medicare wants t see chart ntes reflecting the need fr the care (e.g., treatment plan, histry and physical, perative reprt) frm the patient s medical recrds charted when the patient is being seen (physician s ffice, hspital, nursing hme, etc.). T be n the safe side, it is recmmended that this infrmatin be cllected up-frnt t be sure the physician s dcumentatin supprts the claim. Each dcument must be signed and dated, and include the signee s printed name and credentials. We highly recmmend that an Attestatin r Signature Lg be included when respnding t audit requests. Electrnic signature and date is nly allwed n electrnic dcuments. All dcuments that supprt medical necessity must be signed and dated prir t the delivery date. Each page/chart nte must clearly identify the patient. The amputatin side shuld be clearly and cnsistently identified. Physician Dcumentatin: The fllwing infrmatin must be included in the rdering physician s medical recrds: Recent histry and physical examinatin (fcus shuld be n the amputatin, prsthesis, and ambulatry difficulties). a. Histry f the Injury, Illness, r Cnditin Diagnsis/etilgy f amputatin(s) Date and affected side (s) Clinical curse Therapeutic interventins and results Prgnsis b. Physical Examinatin Height, weight, recent lss/gain Cgnitive ability t use & care fr new prsthesis Descriptin f the residual limb ( e.g. lcal and/r phantm pain; wund healing issues; skin irritatin, breakdwn, infectin; limb vlume changes r swelling; weight fluctuatins; muscle atrphy r cntractures; stearthritis, r ther arthritic cnditins f the residual limb jint(s)). Cardipulmnary, musculskeletal, neurlgical, arm and leg strength, ROM, gait, balance, crdinatin Lwer Limb Prsthesis Dcumentatin Guide Ottbck 1

2 c. Functinal Limitatins Describe the nature and extent f limitatins n a typical day that might affect the patient s ability t use/ambulate with the new prsthesis. Nte: Any cnditin identified must be ruled ut. Examples: Cardipulmnary cnditins that might limit the patient s capacity [e.g. cngestive heart failure (CHF), crnary heart disease (CHD), endcarditis, mycarditis, arrhythmias, peripheral arterial (cclusive) disease (PAD/PAOD), chrnic venus insufficiency (CVI) with recurring ulcers, lymphedema]. Musculskeletal cnditins (e.g. stearthritis sund side leg jints, spinal stensis, severe lw back pain). Neurlgical cnditins that cause impairments in gait, balance r crdinatin (e.g. MS, strke, SCI, Parkinsn s, peripheral nerve lesins, lumbar disc herniatin with mtr paresis, dementia/alzheimer s disease, depressin, psychiatric disrders/diseases). Other cmrbidities (e.g. chrnic kidney failure, chrnic liver failure, cancer with chemtherapy/radiatin, general decnditining). d. Impact f the Limitatins: Descriptin f current activities f daily living and hw they are impacted by the deficit(s) identified. Is the patient mre limited by his/her medical cnditins r by the functin f the prsthesis? e. Ambulatry Assistance currently used (e.g. cane, walker, wheelchair, care giver). Nte: Medicare des nt cnsider a persn wh permanently uses an ambulatry aid t be functining at K3 level. If this is a temprary situatin, state in yur pinin hw lng it will take fr yur patient t be back t functining at K3 level (free f the assistive device). Functinal Levels (K-Levels) Level 0: Des nt have the ability r ptential t ambulate (r transfer safely) with r withut assistance and a prsthesis des nt enhance their quality f life r mbility [ i.e. patient likely will nt be able t ambulate at all]. Level 1: Has the ability r ptential t use prsthesis fr transfers r ambulatin n level surfaces at fixed cadence [i.e. patient likely will be able t use the prsthesis within his/her dwelling nly]. Level 2: Has the ability r ptential fr ambulatin with the ability t traverse lw level envirnmental barriers such as curbs, stairs r uneven surfaces [i.e. patient will likely be able t use prsthesis within his/her dwelling and a limited radius in the cmmunity]. Level 3: Has the ability r ptential fr ambulatin with variable cadence. Typical f the cmmunity ambulatr wh has the ability t traverse mst envirnmental barriers and may have vcatinal, therapeutic, r exercise activity that demands prsthetic utilizatin beynd simple lcmtin. [i.e. patient will likely have a prsthetic ability cmparable with that f a nn-amputated persn with n mbility restrictins]. Level 4: Has the ability r ptential fr prsthetic ambulatin that exceeds basic ambulatin skills, exhibiting high impact, stress, r energy levels. Typical f the prsthetic demands f the child, active adult, r athlete. f. Define the Patient s Functinal State: Describe patient s functinal capabilities in terms f the K-Levels (abve) as they relate t the patient s activities. These shuld be real activities, such as walking the dg and related K-level functins that patient encunters (e.g. lng-distance ambulatin, bstacles, types f terrain, slpes, stairs, ramps, crwds, public transprtatin) Lwer Limb Prsthesis Dcumentatin Guide Ottbck 2

3 Fllwing is what must be in the recrd: Patient s activities prir t amputatin Patient s current activities Activities that patient desires t get back t (and has the ptential fr) using the new prsthesis. Nte: If patient was a cmmunity ambulatr (K3/K4) earlier in life, but nt prir t the amputatin due t a medical cnditin (e.g. neurpathy, ulcers, and neurpathic pain) r if patient was never a cmmunity ambulatr (K3/K4) and nw has demnstrated capacity t be ne, include why yu believe the patient will be a cmmunity ambulatr with the new prsthesis (e.g. sund limb is asymptmatic, achievements during rehabilitatin/physical therapy, diseased limb was the primary cause f the mbility restrictins, etc.). g. Dcument the Current Prsthesis: Cnditin f each cmpnent (e.g. scket, knee, pyln, ankle, ft) shuld be dcumented. Reasns fr replacement One f the fllwing reasns shuld be dcumented fr each cmpnent being replaced. Patient s functinal needs have changed Due t physical changes the cmpnent n lnger fits Device is irreparably wrn Device is lst r damaged beynd repair Cst t repair will be greater than 60% f the cst t purchase a new device. If the patient s cnditin has changed, describe why the current prsthesis is n lnger apprpriate. (e.g. weight gain/lss, decreased stability, etc.) If the device was damaged r lst, describe the incident. h. Previus Prstheses: Dcument patient s past experience with prsthetic cmpnents (what has been tried, and the result). Desire and Mtivatin: Dcument patient s desire t use the new prsthesis and mtivatin t ambulate. i. Recmmendatin fr the type f new Prsthesis/ Cmpnent(s) and the medical reasn fr yur decisin. The recmmendatin must be based n patient s prir activities, current cnditin, and desire t ambulate. Include a statement as t what yur decisin is based n. The Brand name f the prsthetic cmpnents is nt required. j. Prgnsis: Dcument patient s prgnsis using the new device, including yur pinin as t apprximately hw lng it will take patient t reach the higher K-Level (if applicable). Dispensing Order The prsthesis/cmpnent may be delivered upn receipt f a dispensing rder; hwever, a signed Detailed Written Order (DWO) must be btained prir t billing. The DWO can be yur dispensing rder if signed prir t delivery. The dispensing rder must cmply with state prescribing and/r ther applicable laws. It is the practitiner s respnsibility t ensure this cmpliance. The dispensing rder can either be verbal and dcumented in the patient s chart OR written by the rdering physician. Fr Medicare, there nly needs t be ne date n the dispensing rder. This will be the rder date. Lwer Limb Prsthesis Dcumentatin Guide Ottbck 3

4 The fllwing elements must be included in the dispensing prescriptin: Patient s name Date f rder Fr written rder: use the date f the prescriptin Fr verbal rder: use the date the call was received Descriptin f item Signature Fr written rder: Physician s signature and date, printed name and credential Fr verbal rder: Printed name f persn taking rder, signature, date, time. Detailed Written Order (DWO) The prvider may write the detailed rder; hwever, the physician must review and sign it. Tw dates are required n a prvider generated DWO (rder date and physician s signature date) The DWO must be signed & dated by the rdering physician prir t submitting the claim, but culd als be the Dispensing Order if signed prir t delivery. Signature/date stamps are nt allwed. Describe what is being rdered (list all items, ptins r additinal features that will be separately billed r require an upgraded cde ) Effective 11/20/2017: Yu may use ne f the fllwing methds: Narrative descriptin (AK plycentric knee w/frictin) HCPCS cde (L5613), HCPCS cde narrative (Additin t lwer extremity, endskeletal system, abve knee, knee disarticulatin, 4-bar linkage, with frictin swing phase cntrl) Brand name/mdel number (4R36 Titan plycentric knee jint) *We recmmend including brand name and mdel number fr items with multiple cdes. Nte: Always include RT/LT Physician demgraphics (printed name, credential, address, phne, NPI) Physician s handwritten signature and date Nte: If this is the nly rder and the prsthesis will be delivered same day, the physician shuld include the time f signature t prve that the rder was signed prir t delivery. The fllwing elements must be included in a prvider generated DWO: Order date Use the date f the dispensing rder if yu have ne. If yu d nt already have a dispensing rder, use the dated that the DWO is generated by the prvider. (tday s date) The physician s signature date des nt have t match the rder date. Patient s name n each page Prsthetist s Dcumentatin Medical recrds must supprt that the device is still medically necessary. Medicare expects that a lst/damaged item wuld be reprted t sme authrity (e.g. plice, hmewners insurance, etc.) and requires that a cpy f that reprt be available. If patient did nt reprt the accident/lss, yu will need a signed statement frm the patient describing the incident. Lwer Limb Prsthesis Dcumentatin Guide Ottbck 4

5 a. Functinal Evaluatin (K-level shuld match physician s evaluatin) (see sectin f. Physician Dcumentatin) Activities prir t amputatin Activities that patient did in the past and wuld like t get back t using a new device (e.g. hme, wrk, therapeutic, exercise). Current activities. Fcus n activities that the new prsthesis will allw that the current prsthesis des nt. Describe difficulties, such as falls, stumbles, nt making it acrss street befre light changes, inability t change speed when needed, etc. Hw will patient be able t d it better with the new prsthesis? Ptential future activities. If these vary frm prir activities, an explanatin will be required) b. Histry f Prsthetic Use Yur recrds shuld have a histry f each prsthesis patient has used/trialed in the past. Brand f cmpnent Hw lng did patient use it? What was the result? c. Current Prsthesis Histry f each cmpnent being replaced (age, cnditin, hw did it wrk ut?) Descriptin f the labr invlved (e.g. casting, mdificatin, time, tls used, materials used, where was material applied, etc.) Reasn fr replacement (e.g. item lst r damaged beynd repair; change in patient s cnditin and device n lnger fits r des nt meet functinal needs; item is wrn and cannt be repaired r the cst t repair is greater than 60% f the Medicare allwable fr a new device). d. Recmmendatin fr the type and brand f the new prsthesis: Must be based n physician s recmmendatin Include ratinale fr yur decisin Include medical necessity and justificatin fr each cde that will be billed. e. Patient s mtivatin and desire t use the new prsthesis (and t ambulate fr lwer extremity) f. Chart nte fr each visit with patient with printed name, credential, signature and date n each nte. g. Patient s name n each page. Prf f Delivery (POD) NEW A signature date is n lnger required; hwever, if there is ne n the frm, it must be the date f service n yur claim. If the DWO is signed n same day as the delivery and it is the nly rder, bth dcuments will need t indicate the time f the signature. Elements t be included n the POD when device is delivered direct t the patient: Delivery Date Patient s name Address where item is delivered (yur ffice, patient s hme, SNF, etc.) The quantity delivered fr each item Amputatin side fr each item, LT/RT Describe what will be delivered Effective 12/21/2017: Yu may use ne f the fllwing methds: Narrative descriptin (AK plycentric knee w/frictin) HCPCS cde (L5613), HCPCS cde narrative (Additin t lwer extremity, endskeletal system, abve knee, knee disarticulatin, 4-bar linkage, with frictin swing phase cntrl) Lwer Limb Prsthesis Dcumentatin Guide Ottbck 5

6 Brand name/mdel number (4R36 Titan plycentric knee jint) *We recmmend including brand name and mdel number fr items with multiple cdes. Signature and printed name f the patient r designee Nte: If designee signs, include the designee s relatinship t the patient and the reasn why patient culd nt sign. This persn cannt have any financial cnnectin t the prvider. Effective 11/20/17 POD when patient is recently eligible fr FFS Medicare and already wn a LL prsthesis Statement that supplier has examined the item, signed by the beneficiary. Statement must meet POD requirements. AND Supplier attestatin that the item meets Medicare requirements. Beneficiary Authrizatin A new authrizatin is required anytime a new prsthesis/cmpnent(s) is prvided. In ther wrds, a new authrizatin is required anytime a new HCPCS cde is billed. This authrizatin shuld give yu: Permissin t submit claims n behalf f beneficiary. Permissin t pay yu directly (assigns the benefits t the prvider). Release t authrize the prvider t btain cnfidential medical infrmatin abut the beneficiary in rder t prcess the claim. Example f an Authrizatin: Name f Beneficiary: HICN: I authrize (supplier) t submit claims t Medicare n my behalf. I request that payment f authrized Medicare benefits be made either t me r n my behalf t (supplier) fr any services furnished me by that supplier. I authrize any hlder f medical infrmatin abut me t release t (supplier) and/r the Centers fr Medicare & Medicaid Services and its agents any infrmatin needed t determine these benefits r the benefits payable fr related services. Signature Date Advanced Beneficiary Ntice (ABN) if required NOTE: Medicare des nt allw blanket ABN s t be issued. In ther wrds ne cannt give an ABN t every patient, in anticipatin that Medicare might deny. ABNs are t be used n a case-by-case basis when there is a clear indicatin that the device will be denied as nt medically necessary/nt reasnable and necessary. References: Jint DME MAC. Lcal Cverage Article: Standard Dcumentatin Requirements fr All Claims Submitted t DME MACs (A55426) CGS & Nridian Supplier Manuals 2018 Ott Bck HealthCare LP Lwer Limb Prsthesis Dcumentatin Guide Ottbck 6