AFO MEDICARE COMPLIANCE GUIDE

Achieving Medicare Compliance with the Richie Brace®

When prescribing and dispensing prefabricated and custom Richie Brace® products, the practitioner has certain obligations in order to be compliant with recent Medicare requirements for reimbursement.This document will outline the basic highlights of what is required for documentation and record keeping.

This is not an official Medicare document and is not a representation of the entire set of policies for dispensing durable medical equipment to Medicare beneficiaries. Therefore, the practitioner is urged to seek further information from the Durable Medical Equipment (DME) Medicare Administrative Contractor (MAC). Reference the DME MAC website for their jurisdiction regarding all rules and regulations for supplying durable medical equipment (DME) to Medicare beneficiaries. For patients with other forms of health insurance, the following guidelines should also be followed as most third-party payors adhere to current Medicare policies.

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Currently, Allied OSI Labs provides a simple All-in-One Necessity Document of patient findings and documentation requirements. This is for the practitioner to complete in order to fulfill the Medicare guidelines.

However, recent audits have shown that a checklist like the All-in-One Necessity Document is not sufficient if the patient’s medical record also does not document the same findings in narrative form.

The checklist can be used as an outline when entering specific information into the progress notes or body of the medical record. Therefore, the All-in-One Necessity Document is helpful and should be completed and enclosed in the medical record of the patient receiving any Richie Brace® product.

The practitioner is also urged to also include a narrative section in the patient’s medical record on the day of prescription, casting, and dispersal of any Richie Brace® product.

Physicians, including podiatric physicians, can prescribe ankle-foot orthoses (AFO’s). Many of these physicians also serve as providers or suppliers of the AFO device. Other practitioners, such as Certified Orthotists and Certified Pedorthists, can only be providers or suppliers and must receive a written order or prescription from a physician in order to supply an AFO to a Medicare beneficiary.

The prescribing physician must document the medical necessity for the AFO device in the patient’s medical record.

In a sense, by documenting that an AFO device is indicated for the specific patient, the prescribing physician has noted in the medical record that the device is being prescribed.

This prescription must be justified based upon medical necessity. The essential requirements for medical necessity of an AFO device include:

  • Patient is ambulatory; and
  • Patient has a weakness or deformity of the foot and ankle; and
  • Patient requires stabilization of the foot and ankle for medical reasons; and
  • Patient has the potential to benefit functionally from the use of an AFO

Note: All 4 elements must be documented

Recent audits of prescribers (and suppliers) of AFO devices have shown that patient medical records often do not contain adequate documentation of all four (4) elements of the medical necessity as shown above.

For the common pathologies in which Richie Brace® products are prescribed, sample progress/medical notes are provided. These sample notes may guide the practitioner in documenting the specific findings and indications for prescribing an ankle-foot orthosis.

*See Sample Richie Brace Prescription Medical Record Documentation forms.

CLICK FOR ALL-IN-ONE MEDICAL NECESSITY DOCUMENT

Custom vs. OTC

A recent requirement for all custom-foot orthoses prescriptions is verification that a prefabricated device “could not be fit” to the specific patient.

This used to be optional for custom AFO prescriptions but it is now is an absolute necessity for documentation in the medical record.

The record must specifically state that the patient “could not be fit with a prefabricated AFO”… which the meaning is vague and confusing.

We suggest that severe deformity will preclude the fitting of a prefabricated device and the specifics of the deformity should be spelled out. Alternatively, the practitioner can try to fit a prefabricated Richie Brace® in the office and document that proper fit could not be achieved.

In addition, one more criteria for prescribing a custom AFO device must be documented in the medical record. The criteria should be selected from the following list, i.e. pick all that apply:

  • Condition necessitating the orthosis is expected to be permanent or of longstanding duration (more than 6 months); or
  • There is a need to control the knee, ankle, or foot in more than one plane; or
  • Patient has a documented neurological, circulatory, or orthopedic status that requires custom fabricating over a model to prevent tissue injury; or
  • Patient has a healing fracture that lacks normal anatomical integrity or anthropometric proportions.

Note: In almost all cases, custom Richie Brace® products are utilized to control the ankle and foot in more than one plane. In many cases, the condition is expected to be treated for a duration exceeding 6 months.

We suggest at least 2 criteria be utilized and appear in narrative form in the patient medical record.

Effective for claims with dates of service (DOS) on or after 3/1/2019, suppliers must bill each item on two separate claim lines using the RT and LT Modifiers and 1 USO on each claim line. Do not use the combination RTLT modifier on the same claim line and bill with 2 unites of service (UOS). Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or with the RTLT on a single line, will be rejected as incorrect coding.

The physician supplier should not ordinarily be required to write an order (prescription) to him or herself for supplying an AFO device to their own patient. As stated above, the physician should state in the medical record that an AFO brace is being prescribed on this date with the medical necessity of the prescription clearly spelled out in narrative form.

In addition to the narrative “prescription” of the AFO device contained in the medical record, Medicare requires that a copy of the vendor (Richie Brace® lab distributor) prescription form or purchase order be kept on file for each and every brace dispensed. The invoice provided by the lab distributor should also be kept on file. Both of these documents may be requested by Medicare in a prepayment audit.

However, recent prepayment audits have revealed some confusion on the part of the DME MAC when looking for required documentation of AFO brace suppliers. The reviewer does not always realize the physician is also the supplier. Despite adequate progress notes being submitted by the physician/supplier, a demand has been made for a “written order,” which is ordinarily only required by suppliers such as orthotists and pedorthists.

Therefore, we recommend that all physicians dispensing Richie Brace® products complete a detailed written order which is kept in the patient’s medical record. This written order must include the following information and can be written on an ordinary physician prescription form:

  • Beneficiary’s name
  • Physician’s name
  • Date of the order and start date (if start date is different than date of order)
  • Detailed description of the item(s)
  • Physician signature and signature date

Proof of Delivery

The supplier must document a proof of delivery on the day of dispersal.

This document must be signed and dated by the patient. It can be kept in a separate folder or can be inserted into the patient’s medical record. The elements of this document are:

  • Beneficiary’s name
  • Delivery address
  • Detailed description to identify the item(s) being delivered (i.e. brand name, serial number, narrative description)
  • Quantity delivered
  • Date deliverey
  • Beneficiary (or designee) signature and date of signature

In addition to the proof of delivery, the patient’s medical record should include a narrative description of the patient encounter. It should document the fitting and instructions provided for use to the patient. It should also verify that the patient signed and dated the proof of delivery slip and received the “Abbreviated 30 MEDICARE DMEPOS Supplier Standards” document.

Click for fuller version of the Supplier Standards

These sample notes are offered as an example and should not be used as a template or substitute for original medical record documentation specific to an individual patient. There is no guarantee that these suggested sample notes will be accepted or will be adequate for ultimate review by Medicare or any third-party insurance payor.

These sample notes are to be used as a guideline according to current published Medicare criteria for documentation of medical necessity of ankle-foot orthoses. All providers of ankle-foot orthoses are ultimately responsible for proper record keeping and compliance with regulations for reimbursement from all payors.

The sample medical record notes presented here are relevant to the “Treatment Plan” portion of the medical record and are not intended to fulfill the entire amount of information that must be documented.

It is imperative that the physician/provider document the specific clinical findings of each patient in a separate part of the medical record (“Examination” section). This validates the conclusion which is summarized in the sample medical record notes (“Treatment Plan”).

EXAMPLE 1

EXAMPLE 2

EXAMPLE 3

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