On July 31, O&P practitioners tuned in to a special Open Door Forum hosted by CMS to suggest clinical elements that should be included in the electronic clinical template for lower limb prosthesis.

At the beginning of the forum, CMS clarified that the template is intended as an educational effort to help physicians understand what CMS needs to document to satisfy coverage requirements for lower limb prostheses. The forums are meant to help CMS identify a list of data elements that physicians need to document during a face-to-face visit with a Medicare beneficiary about to receive a lower limb prosthesis.

“It seems that there is some confusion that we’re attempting to develop some kind of a form that can be filled out and it is worth spending a minute to say that is not what we’re trying to do. What we’re trying to do is relieve some of the documentation issues that have resulted in payment error, specifically with respect to some DME items like lower extremity prostheses,” Michael Handrigan, MD, medical officer for the provider compliance group at CMS, stated during the forum. “If we can identify the right data elements that will help the Office of the National Coordinator for Health Information Technology create the electronic standards then that will allow the industry to develop the right electronic tools to insert into electronic health records.”

O&P insight

During the forum, several practitioners made suggestions for updating the electronic template. One of these suggestions was to make the form shorter and easier for physicians so that they do not rush through the process and make it as accurate as possible. This could be done by including a box to check in each section if there was nothing that interfered with the patient’s ability to use a particular type of prosthesis.

Receiving prior authorization was another suggestion and would change the way billing is done. Instead of filing the patient’s documentation with a claim, CMS would review the patient’s documentation and authorize the prosthesis before it is prescribed to the patient, which would ultimately save CMS money from paying for prostheses that are inappropriate for certain patients.

Practitioners also pointed out some errors on the template background, such as the correct usage of the word “prosthetic.” They also said the CMS template wrongly indicated that the lower limb devices should be categorized by K-level, whereas the K-level actually designates the amputee’s functional ability. It was recommended that the paragraph be reworded to state that an amputee with a low functional level will not be prescribed a higher functional level knee, foot or ankle that also has a higher cost.

Practitioners also questioned whether it was appropriate for the physician to decide the K-level for an amputee. CMS clarified that it does not expect the physician to state a K-level for the patient, but the documentation on functional capabilities and general health status need to support the ultimate K-level device the patient is prescribed.

Besides offering recommendations on how to rewrite the template, several practitioners had strong opinions about how the template was regarded in their professions. One opinion held by O&P practitioners who called in was that it is important for them to collaborate with physicians to compile the necessary information for CMS. But they said they found it unfair that liability falls on the O&P provider if the physician fails to cooperate. Several O&P practitioners have found this problem occurs often with surgeons, who will amputate a leg, but then say they will not provide a prescription for a prosthesis. Because CMS does not have the authority to change that rule, they recommended the industry take it up with Congress.

CMS stated physicians were not prohibited from referring the patient to a licensed clinical medical professional, such as a physical therapist, or for physicians to consult a myriad of medical professionals.

“Using a physical therapist is a win, win, win because the therapist doesn’t have a financial interest, the prosthetist gets a second opinion and the doctor gets a third opinion,” Raymond Fikes, CP, from Arizona, stated. “We’re finding that the therapist can gather almost all the data that is not already contained in the doctor’s chart, which includes all the vital information and comorbidities.”

Several O&P practitioners also voiced concern during the forum that the more details physicians had to include in their reports, the easier it would be for recovery audit contractors to find something missing and deny their claim. However, CMS said that this was a generalized statement for only specific claims, and did not apply to every claim.

“[The Electronic Clinical Template for Lower Limb Prosthesis] is not intended to create a list of things that a physician needs to fill out in its entirety. It is intended to highlight the important areas that can support medical necessity for the device that’s ordered, and that will certainly depend on the specific device that the physician orders,” Handrigan said. “For example, if the cardiovascular system is an important aspect of the overall health status then these are the elements within that section that we feel are important for the physician to fill out. It’s really intended to create an electronic backdrop for an electronic system that ultimately will be able to walk the physician through the right elements to enter, not necessarily all of them on one particular patient.”

Future expectations

Currently, CMS is working on setting up an electronic health record system for the O&P industry with the hope that one day all patient medical information may be accessed between health care EHR systems.

“We have looked at all of our privacy rules and the legal rights that we have to medical records and we think that, given the laws and statutes that are in place today, it works better for the contractor to request [medical records] and for the provider to submit the records,” Melanie Combs-Dyer, deputy director of the provider compliance group at CMS, stated. “What we are working toward would be a day where that could happen even more quickly than it does today electronically.”

Providers are encouraged to direct questions to eclinicaltemplate@cms.hhs.gov. The next Open Door Forum for the electronic clinical template for lower limb prosthesis is scheduled for Sept. 11 at 4 p.m. EDT. — by Casey Murphy

Disclosure: Combs-Dyer, Handrigan and Fikes have no relevant financial disclosures.