PRESENTED BY: Aaron Sorensen, MBA, CPO, LPO O and P Billing Solutions, Inc.

Transcription

1 PRESENTED BY: Aaron Sorensen, MBA, CPO, LPO O and P Billing Solutions, Inc.

2 ! General Medicare Coverage Guideline! General Lower Extremity Prosthetic Policy! Documentation Pitfalls Documentation Principles Documentation Interpretation! K-level Exempt Coding Considerations

3 ! The medical record is not limited to physician s office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc.

4 ! Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for the purpose of determining that an item is reasonable and necessary

5 ! A lower limb prosthesis is covered when the patient: Will reach or maintain a defined functional state within a reasonable period of time; and Is motivated to ambulate " ***Exception based on CGS webinar " K1 for transfers " Document capable of transfers and need

6 ! A determination of the medical necessity for certain components/additions to the prosthesis is based on the patient's potential functional abilities. Potential functional ability is based on the reasonable expectations of the prosthetist, and treating physician, considering factors including, but not limited to: The patient's past history (including prior prosthetic use if applicable); and The patient's current condition including the status of the residual limb and the nature of other medical problems

7 ! CMS does not care too much about what you have to say, it s more about what you do not say! If your internal documentation is not on par, they do not need to go further ***New policy change (Spring 2014) " If you do not have proper supporting documentation for claim 1, each successive claim related to that claim may be denied!!!!! Clinician s notes should be presented very clearly DO NOT want the review agent s job to be difficult Typed, not hand written

8 ! LCD DOES NOT define the format your note or MD note must be completed! SOAP is the most recognized, not required, format! What is SOAP? It is a documentation method employed by health care providers to create a patient s chart. There are four parts of a SOAP note: Subjective, Objective, Assessment, and Plan.

9 ! Charting Comparison New approach " SOAP less focus " LCD new focus " Outcomes focus Physician charting " Sectional " Areas of focus " Pt apt details within Prosthetist charting " Try same layout as MD " Breakdown based on LCD policy " Generate note template based on type of appointment

10 ! Review Internal document auditing Support your coding! " Tech sheet auditing " Test socket, 1 or 2? " Lamination materials? " Listed ultralight material? " Acrylic? " Purchasing documents " Foot " Knee " Suspension

11 ! Internal Review Activities " Various amputee mobility predictors " Create your own " Have the pt do an attestation to activities for your records " Have pt bring pictures or videos of those activities " Supporting documents " Brochure with their name listed " Ticket from the activity " i.e. 5K participation document

12 ! Internal Review L-codes " Do the codes match the proper components for the K-level picture you have painted? Supporting documentation in order? " Remember it s not what is said by the provider as much as it is what is not said!

13 ! Review External Documentation review " LCD interpretation key: Contemporaneous charting/ files!? " What k-level picture is painted by the documents of the medical team? " Do the diagnostic tests paint a different picture than what the physician was coached to say? " How many different professionals chart notes do you have? " Are they contemporaneous?

14 ! External Review MD notes " Critical/primary support " Pt s activities listed? " Pt s K-level mentioned? " Surgeries and medications listed? " Surgery record may help " Sports injuries!!!! " Current prosthetic status " Progress notes stating no issues just as important as stating there is an issue " Shows continued need and continued use requirement

15 ! Understand current interpretation LCD is in black and white Interpretation is fluid Moving bulls-eye " Webinar perfect example with K1 transfer amputees Can lead to huge recoupments Documentation drives support of policy compliance

16 ! Think through every claim as if it is going to be audited!! Review ALL supporting documentation Internally and externally generated! Is one physician clinical note enough support regardless of the amount of detail? Your decision Sometimes yes, sometimes no Recommendation, NO!

17 ! Create a checklist (internal) Billing staff to review " LCD coverage for determined K-level " Internal notes " Tech sheets " Invoices " Originating and Detailed Rx " L-code justifications " External Documentation " Clinical notes " Activity discussion " K-level clearly stated " Residual limb status " Pictures/video " Patient supplied documents " Detailed delivery receipt

18 ! Take pictures! Keep invoices organized! Take video! Have patient write testimonial! Get attestations Patient Physician Therapist Activity organizers! Know resources to tap Freedom website

19 ! Receive CMS blasts Check your region website Outreach-and-Education/ Medicare-Learning-Network- MLN/MLNMattersArticles/ index.html?redirect=/ MLNMattersArticles/! Attend CMS sponsored meetings Keep printed materials for appeal purposes! Attend O and P meetings; local, state, regional, national! Attend pt appointments with physician and therapist

20 ! L5968 ADDITION TO LOWER LIMB PROSTHESIS, MULTIAXIAL ANKLE WITH SWING PHASE ACTIVE DORSIFLEXION FEATURE! Currently not K-level dictated with LCD policy restrictions

21 ! Suspension Not K-level dictated in LCD L5781, VACUUM L5671 SUSPENSION LOCKING MECHANISM L5673 SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, FOR USE WITH LOCKING MECHANISM L5679 SOCKET INSERT, SILICONE GEL, ELASTOMERIC OR EQUAL, NOT FOR USE WITH LOCKING MECHANISM L5647/L5652 SUCTION SOCKET

22 ! Freedom Innovations thanks you for your continued support and hopes this series of webinars helps you navigate the tumultuous environment of serving MEDICARE PATIENTS.! Please provide feedback to your Freedom sales representative of future topics to cover and if you find these webinars helpful.! Aaron Sorensen, CPO, LPO! President,OPBS! Ph ! Rob Cripe! VP Global Marketing! Ph