Why Are Our DME Claims Being Audited By Medicare?

Many of us who practice in Jurisdiction D have been audited by Noridian Healthcare Solutions for claims submitted for all types of DME devices including walking boots and custom ankle-foot orthoses. Last week, Noridian Healthcare Solutions released the results of its audit for Jurisdiction D (which covers 17 states including California, Arizona and Washington) for the first quarter of 2014 and the results are alarming.¹ For custom ankle-foot orthoses billed with code L 1970, 86 percent of the claims were denied! For custom AFO devices billed with code L 1960, 88 percent of the claims were denied. For walking boots billed with code L 4360, 80 percent of the claims were denied. We have no idea how many podiatric physicians were included in this “pre-payment review” of over 2,000 claims submitted from Jurisdiction D to Noridian Healthcare Solutions during the first quarter of 2014. However, my own experience in having multiple claims fall under this audit has given me new insight and frustration over this recent trend. What are the top reasons for denied claims for these DME devices, according to Noridian Healthcare Solutions? 1. The treating physician’s records did not provide detailed documentation to support medical necessity of a custom orthosis rather than a prefabricated orthosis. 2. The documentation submitted was insufficient to support custom coverage criteria. 3. The documentation submitted was insufficient to support basic coverage criteria. 4. There was no detailed written order or dispensing order provided. The documentation requirements are identical for all four jurisdictions of Medicare Durable Medical Equipment (DME) providers. Therefore, all podiatric physicians should be aware of these rules in case “pre-payment reviews” are requested of them whenever they are billing walking boots and custom AFO devices. For those who are interested, Noridian Healthcare Solutions does provide a checklist for documentation items required by suppliers of durable medical equipment.² For those suppliers in any of the other three jurisdictions for Medicare DME, please contact the DME MAC for that region to clarify any variations. However, following this checklist does not always ensure that the supplier will survive a pre-payment audit. As someone who is not only a current practicing podiatric physician but a supplier of DME products and the owner of an AFO company as well, I thought I had a good handle on what is required by Medicare for proper documentation. However, even I am confused along with practically every supplier in the country. For example, what does it mean when Medicare stipulates that one cannot dispense a custom ankle-foot orthosis unless there is adequate documentation that the patient “could not be fitted with a prefabricated orthosis”? Does this mean the supplier actually tried to fit a prefabricated device? Alternately, does this mean the supplier knows ahead of time that it would be futile to dispense a prefabricated device? If so, what are the criteria for knowing ahead of time that a prefabricated device “could not be fitted”? Since Noridian Healthcare Solutions does not provide any detailed explanation on this, it is up to the supplier to guess what is required. In this case, I failed my audit for several custom AFO devices and will now resubmit further justification in the hopes that the registered nurse reviewer knows enough about adult-acquired flatfoot to know that prefabricated braces almost always fail due to severe fitting challenges. In regard to “written orders” for DME devices, when the prescribing podiatric physician is also the supplier, he or she cannot write a prescription to themselves. Theoretically, the combined prescriber/supplier only needs to provide progress notes documenting the medical necessity of the prescription as well as a copy of the prescription form sent to the fabrication laboratory. Conversely, non-supplier physicians commonly write a prescription (i.e. a written order which is taken by the patient to the supplier orthotist who then provides the brace). Noridian Healthcare Solutions appears to be confused about this as it has asked me for a “written order” for a custom AFO device I prescribed, even though I wrote a detailed progress note about the justification of the “prescription” and also provided a copy of the prescription form sent to my brace supplier company. From now on, I am going to produce a “written order” whenever I prescribe an AFO device. This written order will contain: Beneficiary name Physician name Date of the order and start date if start date different than date of order Detailed description of the item(s) Physician signature and signature date

What You Should Know About Prescribing Walking Boots

When it comes to walking boots (L 4386), how many podiatric physicians realize they have to write a detailed note in the patient medical record to document the medical necessity of the device, similar to the requirement for custom AFO devices?³ When prescribing and dispensing a walking boot, the medical record must contain documentation that the patient: • is ambulatory; and • has a weakness or deformity of the foot and ankle; and • requires stabilization of the foot and ankle for medical reasons; and • has the potential to benefit functionally from the use of an AFO. (Yes, walking boots are AFOs!)

Final Notes

The Noridian Healthcare Solutions Web site states that its audit saved “improper payment” to hundreds of suppliers of DME devices. The suggestion is that improper payment would be supporting fraudulent claims. The problem is that saving money from fraudulent claims is totally different than saving money by denying payment for claims that are justified and meet all medical necessity requirements from Medicare. When a podiatric physician dispenses a walking boot to treat an ankle fracture or tendon rupture in a qualified Medicare subscriber, he or she is not committing fraud. When a Noridian Healthcare Solutions nurse carries out an outrageous scrutiny of the patient’s medical record and finds one omission of meaningless information (i.e. is there documentation that the patient “has the potential to benefit functionally from the walking boot”?), the claim should not be considered “improper,” suggesting some mischievous behavior on the part of the doctor. Why not look for blatant fraud, such as billing for fall prevention braces that do not qualify for reimbursement under Medicare criteria? In the meantime, Medicare subscribers (patients) will be the losers as suppliers already are holding back on providing durable medical goods to their patients. Even though the use of these devices is justified, doctors simply do not want to get caught paying for devices and receiving no reimbursement, even when they follow all the rules. References 1. Noridian Healthcare Solutions. Ankle foot/knee ankle foot orthosis (HCPCS L1970, L1960, L4360) quarterly results of widespread prepayment review. https://www.noridianmedicare.com/dme/news/docs/2014/05_may/ankle_foot_knee_ankle_foot_orthosis_hcpcs_l1970_l1960_l4360_quarterly_results_of_widespread_prepayment_review.html . Accessed May 22, 2014. 2. Noridian Healthcare Solutions. Ankle-foot/knee-ankle-foot orthosis. https://www.noridianmedicare.com/dme/coverage/docs/checklists/ankle-foot_knee-ankle-foot_orthoses.html . Accessed May 22, 2014. 3. Noridian Healthcare Solutions. Archived LCDs and policy articles. https://www.noridianmedicare.com/dme/coverage/archived_lcd.html . Accessed May 22, 2014.