In February 2018, vHG informed you that legislation was passed that CMS will now consider orthotist and prosthetist notes as part of the patient’s medical record. The legislation included an amendment to 13 Section 1834(h) of the Social Security Act (42 U.S.C. 1395m (h)) to include the following information:
‘‘(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).”.
Manual and policy updates with the new information was pending at that time and has now been added to the Lower Limb Prostheses (LLP) Local Coverage Determination (LCD). The update includes the following verbiage:
“When submitting a prosthetic claim, the billed code for knee, foot, ankle and hip (HCPCS codes L5610-L5616, L5710-L5780, L5810-L5840, L5848, L5856, L5857, L5858, L5859, L5930, L5961, L5970-L5987) components must be submitted with modifiers K0 - K4, indicating the expected beneficiary functional level. This expectation of functional ability information must be clearly documented and retained in the prosthetist's records. The simple entry of a K modifier in those records is not sufficient. There must be information about the beneficiary’s history and current condition which supports the designation of the functional level by the prosthetist.”
Although prosthetist and orthotist documentation can now be used to support functional status and medical necessity for LLPs, the physician is still required to document medical need within their notes. Physicians should document information such as the reason the patient required the amputation and status of residual limb. It is also important that such information coincides with the documentation by the orthotist or prosthetist. The orthotist or prosthetist should be documenting current functional abilities and potential abilities to support functional level such as occupation, daily routine and activities encountered throughout the day, hobbies such as fishing, hiking, exercise, and living accommodations to include steps, floors, etc.
Documentation from the physician and orthotist/prosthetist will now be used for medical necessity and claims audits. This will be a positive approach in taking care of all amputees.