The past two forum postings have reviewed the DMEPOS prior authorization process and the clinical requirements for L1951. This last forum posting on this subject will discuss more on the specific requirements for providers who dispense L1951 and how to successfully navigate the post payment audit process.
As has been previously noted the AFO as described by L1951 includes the fitting and adjustment of this device. The confusion some providers face is that many choose to have their chosen laboratory both assemble and customize from the various parts, so that they receive a device that is already fully assembled. In this common example, the laboratory is working as your agent and everything they do is prior to delivery. Unfortunately, your measurements and the laboratories actions on your order are not consistent with Medicare’s definition of “At the Time of Delivery.”
That being the case, what must I do and document to fulfill the LCD requirements of includes fitting and adjustment or custom fitted, at the time of delivery, specifically for L1951.
Some examples of documentation would include, the external clips provided by the laboratory required specific placement by a qualified provider and thus not subject to the definition of minimal self-adjustment.
What you are telling CMS (and any of their agencies) is that the placement of the clip is essential to the proper functioning of a complicated AFO requiring the skills of a qualified provider, beyond the definition of “minimal self-adjustment rules.”
In addition, applying these clips on different types of shoes in different locations is mandated by the manufacturer and determined by the patient’s clinical requirements. Also placing the device itself on the proper anatomical location of the shoe(s) is something beyond the skills set of a non-qualified provider. If you wish to add a stop to inhibit dorsiflexion or plantarflexion, as delineated in the Instructions for Use (IFU) ) or similarly heat and twist the frame to encourage or reduce frontal plane motion (again as per the Instructions for Use), this also must be documented and is consistent with the custom fitting requirements.
It is imperative to understand that the RAC is not going to hunt for this information if you cavalierly refer to the IFU in your note. The RAC is only paid by CMS if they hold you at fault and are successful in monetary recovery. Thus, your documentation must be very clear regarding those steps you took to customize the device at the time of delivery and that you as a physician who is qualified to perform such procedures. Documenting that all the steps you took are far beyond the scope of the “minimal self-adjustment requirements” may also be beneficial.
Should the RAC find you are at fault, appealing the claim can be accomplished during the 30-day discussion period by requesting a peer-to-peer review. Failing this, one can also appeal your claim to the original DMEPOS carrier. All appeal information is included in any correspondence you will receive from the RAC.
