Assuming all the clinical requirements for the medical necessity for custom foot orthotics have been met, what other issues must the chart documentation address?
There are two major issues which must be documented, relating to orthotic fabrication and dispensing. This week’s column will address the fabrication process and a future article the dispensing.
The orthotic fabrication process includes everything from the impression to receiving but not fitting and dispensing the device. Let’s look at some major elements in the fabrication process which require documentation:
Patient positioning: What position was the patient in for the impression? Were they prone or supine? Was the patient wt. bearing, semi wt bearing or off wt bearing. If the latter were they in subtalar neutral, was the first metatarsal plantarflexed, etc.
Negative Impression: What technique was used? Was the patient cast with fiberglass stocking, plaster, scanned?
The orthotic prescription: Dr. Blake and others have written extensively on the required clinical elements of the prescription for various conditions. From the reimbursement perspective and from experiences with audits it is of primary importance to provide as extensive a prescription as possible. A separate complete chart entry of the prescription is not required, as long as a prescription form (most often from the laboratory) is kept on file in the patient’s medical record.
Aside from the prescription, the clinician’s name, date and signature should include the patient’s demographics (name, age, height, weight, occupation, etc.) the durometer of the shell, name and thickness of the material along with the heel cup depth. These last two parameters are most often looked at on post payment recoupment attempts. It would be inappropriate to have a low-density durometer and low heel cup for a patient with plantar fasciitis and expect carrier reimbursement. Also, it is important to include any appropriate options to the device including arch fill, posts, cut outs, padding and wedges and the materials used for those modifications. Other important options to document are inversion of the cast, skives and just about any other modification and the rationale behind it should be documented. Most if not all of these options are available on the Kevin Root Medical form.
Any changes to your prescription that the laboratory may make on a follow up discussion with you must also be documented in the medical record, just as you would if a pharmacy called to report a change in the medication you were ordering.
While the above may seem overwhelming, these steps are part of the normal thought process all clinicians should have when prescribing foot orthotics.
The last two columns have discussed the first two steps in the documentation process for foot orthotics. The next column will discuss the proper steps for documenting the dispensing of foot orthotics.
