Guidance on Documentation Requirements for Medicare Recovery Audits

Transcription

1 Guidance n Dcumentatin Requirements fr Medicare Recvery Audits

2 Instructins fr Ordering Physicians Medicare requires that rdering physicians chart ntes in the patient s medical recrds t reflect the need fr care. The patient s medical recrd shuld cntain adequate dcumentatin f the patient s medical cnditin t substantiate the need fr the type and quantity f the prescribed items and the frequency f use and/r replacement. This dcumentatin shuld include the patient s diagnsis, duratin f the patient s cnditin, clinical curse (whether wrsening r imprving), prgnsis, nature and extent f functinal limitatins, therapeutic interventins and their results, past experience with related items, etc. It is recmmended that this infrmatin be prvided t prsthetists prir t dispensing the prsthetic device, t facilitate the recvery and reimbursement auditing prcess. It is imprtant that the amputatin side be clearly and cnsistently identified in the patient s medical recrd. This is especially imprtant fr patients with multiple amputatins. Definitin f Patient Medical Recrd As defined by the Centers fr Medicaid and Medicare Services (CMS): The patient s medical recrd is nt limited t the physician s ffice recrds. It may include hspital, nursing hme, r HHA recrds and recrds frm ther healthcare prfessinals. 1 Amputatin Histry The patient s medical recrd shuld include: Dcumentatin f patient s medical histry assciated with the amputatin, including: Initial diagnsis leading t the amputatin prcedure Date amputatin prcedure was perfrmed Part f the bdy amputated Clear descriptin f patient s clinical curse Clear descriptin f therapeutic interventins and their results Prgnsis expected utcmes given patient s histry. Descriptin f patient s functinal limitatins and capabilities experienced n a typical day: Descriptin f patient s ability t perfrm activities f daily living (ADLs) and hw they are impacted by deficit. Diagnsis fr deficiency in functinal status; these shuld include ICD-9 cdes. Cmrbidities, either related t functinal deficiencies r which culd ptentially impact use f a new prsthesis; ICD-9 cdes fr cmrbidities shuld be included. Indicatin f ther devices used fr ambulatin (e.g., cane, walker, wheelchair), either prir t amputatin r in additin t the prsthesis. Descriptin f patient s functinal capabilities prir t amputatin. 1 See CMS Manual System Pub , Medicare Prgram Integrity Manual, Chapter 5, 5.7 Guidance n Dcumentatin Requirements fr Medicare Recvery Audits 1

3 Descriptin f patient s current functinal capabilities; functinal capabilities shuld crrespnd t K-level definitins. Descriptin f patient s expected functinal capabilities. Explanatin fr the difference in patient s functinal capabilities prir t amputatin and current r expected capabilities. NOTE: If prsthetist evaluates patient s functinal capability, this must als be dcumented in the patient s medical recrd. This evaluatin shuld be dated and the physician shuld restate patient s functinal capability in a separate chart nte and indicate agreement/disagreement with prsthetist s assessment and the ratinale fr this decisin. Clearly indicated status f current prsthesis/cmpnent(s) and reasn fr replacement (if relevant). Patient s past experience with related items (previus prstheses/cmpnent(s) use). Assessment and dcumentatin f patient s desire t ambulate. Clearly indicated recmmendatin fr new prstheses/cmpnent(s). Patient s medical recrd shuld include a recent physical examinatin that fcuses n bdy systems that are respnsible fr patient s ambulatry capabilities r which impact their functinal ability. This exam shuld include, but nt be limited t: Weight and height (nting any weight lss r weight gain) Cardipulmnary examinatin Musculskeletal examinatin Arm and leg strength and range f mtin Neurlgical examinatin Gait assessment Balance and crdinatin. Guidance n Dcumentatin Requirements fr Medicare Recvery Audits 2

4 Nte : K-levels are defined by Medicare based n an individual s ability r ptential t ambulate and navigate their envirnment. Medicare uses a persn s K-level t determine cverage fr prsthetic devices as fllws: K-Level Descriptin Ft/Ankle Cmpnents K0 K1 K2 K3 K4 Patient des nt have the ability r ptential t ambulate r transfer safely withut assistance, and a prsthesis des nt enhance their quality f life r mbility. Patient has ability r ptential t use a prsthesis fr transfers r ambulatin n level surfaces at fixed cadence a typical limited r unlimited husehld ambulatr. Patient has the ability r ptential fr ambulatin with the ability t traverse lw-level envirnmental barriers, such as curbs, stairs r uneven surfaces a typical cmmunity ambulatr. Patient has the ability r ptential fr ambulatin with variable cadence a typical cmmunity ambulatr with the ability t traverse mst envirnmental barriers and may have vcatinal, therapeutic r exercise activity that demands prsthetic use beynd simple lcmtin. Patient 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 a child, active adult r athlete. Nt eligible External keel, SACH feet r single-axis ankle/feet Flexible-keel feet and multi-axial ankle/feet Flex-ft and flexwalk systems, energy-string feet, multi-axial ankle/feet r dynamic respnse feet Any ankle/ft system Knee Cmpnents Nt eligible Single-axis, cnstant-frictin knee Single-axis, cnstant-frictin knee Fluid and pneumatic cntrl knees Any knee system Detailed Written Order Detailed written rders are required fr all transactins invlving DMEPOS. All rders shuld clearly specify the start date f the rder. It must be sufficiently detailed, including all ptins r additinal features that will be separately billed. This descriptin can be in the frm f a narrative r a list f brand names and mdel numbers. Smene ther than the physician may cmplete the detailed descriptin f the item. Hwever, the detailed written rder must be signed and dated by the treating physician t indicate agreement. Guidance n Dcumentatin Requirements fr Medicare Recvery Audits 3

5 Dispensing Prescriptin The dispensing prescriptin must include: A descriptin f the item prescribed The patient s name The name f the prescribing physician The start date f the rder. Prsthetists shuld maintain the preliminary written rder, r written dcumentatin f the verbal rder; this dcumentatin must be available upn request frm CMS r any agents representing CMS. Items may be dispensed based n verbal rders. Hwever, verbal rders must cntain the printed name f the persn taking the rder, alng with their signature and the time and date f the rder. A written rder must still be btained by a prsthetist prir t submitting a claim. Instructins fr Prsthetists As specified by CMS, prsthetists shuld have the fllwing dcumentatin befre submitting a claim: a dispensing rder, the detailed written rder, the CMN (if applicable), the DIF (if applicable), infrmatin frm the treating physician cncerning the patient s diagnsis, and any infrmatin required fr the use f specific mdifiers r attestatin statements as defined in certain DME MAC plicies. The supplier shuld als btain as much dcumentatin fr the patient s medical recrd as they determine they need t assure themselves that cverage criteria fr an item has been met. If the infrmatin in the patient s medical recrd des nt adequately supprt the medical necessity fr the item, the supplier [prsthetist] is liable fr the dllar amunt invlved unless a prperly executed Advanced Beneficiary Ntice (ABN) f pssible denial has been btained. 2 Dcumentatin must be maintained in the prsthetist s files fr seven (7) years. Prsthetists must maintain prf f delivery dcumentatin in their files. In additin, the prsthetist shuld have the fllwing in their patient recrds: Assessment f patient s functinal ability as defined by K-level definitins, including functinal capabilities prir t amputatin, as well as their current and expected functinal abilities; any differences between the patient s functinal abilities shuld be explained Dcumentatin f current prsthesis/cmpnent(s), including: Histry f prsthesis/cmpnent being replaced (if applicable) Descriptin f labr invlved in replacing prsthesis/cmpnent Reasn fr replacing prsthesis/cmpnent. 2 See CMS Manual System Pub , Medicare Prgram Integrity Manual, Chapter 5, 5.8 Guidance n Dcumentatin Requirements fr Medicare Recvery Audits 4

6 Dcumentatin by the prsthetist f the patient s desire t ambulate Recmmendatin fr new prsthesis/cmpnent(s) based n written rder frm the treating physician, r dcumentatin f verbal rder; this shuld include brand name and mdel number f prsthesis/cmpnent(s) Dcumentatin f each visit with patient with a chart nte; each chart nte shuld have the prsthetist s printed name, credential, signature and date. Prf f Delivery 3 Requirements t apprpriately dcument prf f delivery vary accrding t methd f delivery. CMS recgnizes the fllwing methds f delivery: 1. Supplier delivering directly t beneficiary r authrized representative 2. Supplier utilizing a delivery /shipping service t deliver items 3. Delivery f items t a nursing facility n behalf f the beneficiary. Supplier Delivers Directly t Beneficiary A signed delivery slip is adequate prf f delivery if the supplier delivers the item directly t the beneficiary. The delivery slip shuld include the fllwing: Patient s name Quantity f item delivered Detailed descriptin f item delivered Brand name f item delivered Serial number f item delivered. The date n the delivery slip MUST be the date that the item was received by the beneficiary. Supplier Utilizes Delivery Service t Deliver Items If a shipping service is used t deliver items t the beneficiary, the fllwing are sme examples f adequate prf f delivery: Service s tracking slip Suppliers shipping invice. Supplier Delivers Items t a Nursing Facility Cpies f necessary dcumentatin shuld be btained frm the nursing facility t dcument prf f delivery and usage by beneficiary. 3 See CMS Manual System Pub , Medicare Prgram Integrity Manual, Chapter 4, fr mre infrmatin abut prf f delivery and delivery methds. Guidance n Dcumentatin Requirements fr Medicare Recvery Audits 5