Lower Limb Prosthetics Claims Paid to Ozark Prosthetics and Orthotics Were Not Always Supported by Adequate Documentation.

摘要

Pursuant to sections 1832(a)(1), 1861(s)(6), (s)(8), and (s)(9), and 1861(n) of the Social Security Act, Medicare Part B provides for the coverage of durable medical equipment (DME), prosthetics, orthotics, and supplies (DMEPOS). The Centers for Medicare & Medicaid Services (CMS) contracts with four DME Medicare administrative contractors (DME MAC) to process and pay Medicare Part B claims. When submitting claims to DME MACs, suppliers use Healthcare Common Procedure Coding System (HCPCS) codes as well as modifiers that indicate left or right limb and a functional level. Each claim can include multiple HCPCS codes, each of which represents a different component of the lower limb prosthetic provided by the supplier. A lower limb prosthetic is an artificial replacement for any or all parts of the leg and provides an individual who has an amputated limb with the opportunity to perform functional tasks, particularly walking, which may not be possible without the device. DME MACs develop local coverage determinations (LCD) for some covered DMEPOS items. LCDs describe the circumstances for Medicare coverage for lower limb prosthetics and outline the conditions under which DME MACs will cover those devices. LCDs require that some lower limb prosthetics have minimum functional levels to be covered by Medicare. To be paid for a Medicare DMEPOS claim, the supplier must have on file: (1) written documentation of a verbal order/preliminary written order, (2) a detailed written order, (3) proof of delivery, (4) a beneficiary authorization, (5) information from the treating physician concerning the patients diagnosis, and (6) any information required for the use of specific modifiers or attestation statements as defined in certain DME policies. A DMEPOS supplier should also obtain as much documentation from the patients medical records as it requires to ensure that the coverage criterion for an item has been met. If the information in the patients medical records does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved. This review was completed as followup work to the Office of Inspector General, Office of Evaluation and Inspections, review, Questionable Billing by Suppliers of Lower Limb Prostheses, issued in August 2011. Kessler Heasley Artificial Limb, also known as Ozark Prosthetics & Orthotics (Ozark), based in Springfield, Missouri, supplies lower limb prosthetics.