In the early morning hours today, Congress passed and the President signed a massive budget agreement that sets budget levels for two years, continues to fund the federal government through March 23rd, and sets up a massive omnibus spending bill to fund the federal government through the remainder of fiscal year 2018. One of the provisions in this bill directly impacts the O&P community: Recognition of the prosthetists’ and orthotists’ clinical notes as part of the Medicare patient’s record for purposes of determining the medical necessity of O&P care.
ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES AS PART OF THE PATIENT’S MEDICAL RECORD.
‘‘(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS.—For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).’’
This provision addresses a problem that started in 2011 with publication by CMS of a “Dear Physician” letter that stated that the physician’s notes, not the prosthetist’s, determine medical necessity. This letter, and subsequent CMS guidance, resulted in a raft of unnecessary Medicare denials of O&P claims, many of which still sit at the ALJ level of review awaiting hearings. The clinical notes of the prosthetist or orthotist will now be recognized along with the records of physicians and other professionals involved with O&P care. NAAOP expects this provision to impact the reversal rate of Medicare O&P denials in favor of O&P practitioners at all levels of administrative appeal.
NAAOP congratulates and thanks AOPA and its lobbyists for their leadership on this provision, as well as NAAOP’s membership, the O&P Alliance organizations, the Amputee Coalition, and the ITEM Coalition, all of which worked to achieve enactment of this legislation. NAAOP and the O&P community will continue the fight to enact two additional provisions from the Medicare O&P Improvement Act (S. 1191 and H.R. 2599), namely:
- Section 7 of the Medicare O&P Improvement Act: This provision clarifies Congressional intent regarding the definition of “minimal self-adjustment,” which defines off-the-shelf orthotics for purposes of competitive bidding.
- Section 8 of the Medicare O&P Improvement Act: This provision would direct CMS to finally implement long-overdue regulations for Section 427 of the Benefits Improvement and Protection Act of 2000 (BIPA), which links the right to bill the Medicare program for custom fabricated orthotics and prosthetics with the qualifications of the practitioner or supplier. This is an important fraud & abuse and patient protection.