What must I document in my patient’s chart to document medical necessity for custom foot orthotics? This is a common question asked by many of my clients. There are many issues to address within this question.
Beyond the obvious of the clinician’s determination of medical necessity, does the documentation meet the criteria of the third-party payer’s policy qualifying the patient for foot orthotics?
Let’s start with the patient’s diagnosis. Perhaps there is no coverage for foot orthotics at all or the patient’s diagnosis/condition is not covered. At that point, you should educate your patient on why your medical determination does not meet the criteria of the third-party payer and why this now becomes a self-pay transaction. For some carriers you may still need to go through the moot point of a prior authorization and denial. This seemingly needles process is required however to avoid any future conflicts with the carrier and/or patient.
Once the patients’ diagnosis/condition satisfies the merits of the policy the next issue to research is the time component. Many third-party payers require the patient to have a qualifying condition for a specified period which has failed to respond to other conservative treatments. Taking plantar fasciitis as a qualifying condition, does the chart document that the patient has tried and failed other conservative options which have failed for the specified time frame called for within the policy?
In many cases the above may be a mixed bag, perhaps the patient is hypertensive or has diabetes and GERD and NSAIDS or steroid injection are contraindicated. If that is the case, documentation of comorbidities and either the patient’s refusal or contraindication to these treatments must be documented in the patient’s chart.
If the patient did receive other conservative treatments in addition to the above those should be documented in the chart. Some examples include a stretching program, physical therapy notes, failed or previous treatment by another provider, a biomechanical change due to trauma, disease etc. requiring a change in orthotic prescription should all be documented.
Once the above has been documented one should determine whether prior authorization is required or not. If so, the patient’s chart notes should be submitted for approval. If prior authorization is not required, one should review the policy with the patient. In some cases even when prior authorization is not required, it can either be not financially responsible to provide orthotics through the carrier or there may be a carve out to a more limited panel in which case the patient must be referred out to another vendor, or the patient can be asked to sign a waiver of liability in order to accept full liability for payment for the orthotics.
As Dr. Blake and others and others have written in this forum, documentation of a thorough history and biomechanical examination (including gait analysis) is crucial documentation to assisting you in determining the correct orthotic prescription for the patient. However, it is also crucial in assuring reimbursement.
The next column will review what must be documented in the foot orthotic prescription.
