Review and Update Patient Files to Remain Compliant with CMS

CMS has implemented stricter rules regarding documentation. In order to
remain compliant, pedorthists must document and detail their patient files.
Everything must be recorded and organized. According to Dean Mason, CPed, CO,
these are the new rules to which pedorthists must adhere.

“CMS makes the rules, we have to follow them,” Mason told the
audience at the 2010 North American Pedorthic Congress in Orlando, Fla. “I
hate to scare everybody, but this is the reality. They tell us what to do
whether we like it or not.”

Beginning July 1, 2010, pedorthists were required to note the location
and type of amputation and/or lesions in their patient files. Mason recommended
pedorthists review all of their patient files and update their information if
necessary to meet these regulations.

“No longer will it be that you just make an examination,”
Mason explained to attendees.

If there are ulcerations on a patient’s foot, pedorthists should
note the area of the ulceration and document the size. According to Mason,
pedorthists should put everything on paper. He recommended documenting the
healing process with photographs and then detailing the photographs.

“Times are changing,” Mason explained, urging pedorthics to be
sure to read e-mails that come from the Pedorthic Footwear Association (PFA)
for updates and information.

One concern pedorthists must keep in mind is therapeutic shoe
documentation. Simply writing “poor circulation” will not be enough
to justify the medical necessity of shoes, he said.

“Poor circulation is going to be a problem because this was the
catch all. If you are diabetic, odds are you also have poor circulation,”
Mason explained. “Describe the poor circulation in greater detail.
Pedorthists must receive detailed descriptions of the circulatory problems from

According to the PFA website, in a recent medical review audit of
therapeutic shoes and inserts by the National Government Services, Jurisdiction
B Medical Review department, the most common errors found were:

  • medical records fail to document coverage criteria;
  • certification form is not obtained yearly;
  • supplier records fail to document necessity for custom fabricated
  • information not provided to confirm correct coding inserts;
  • information not provided to confirm correct coding of shoes;
  • medical necessity not documented for patients in nursing facilities;
  • no delivery slip and;
  • no documentation received.

Before a pedorthist can even work with a patient, he or she must first
receive an evaluate and treat order from a prescribing physician. This allows a
pedorthist to start their evaluation. Certifying physicians must be a MD or DO.
The pedorthist’s patient file must also include detailed listing of
diagnoses and billing codes from the prescribing physicians.

Mason also explained that in order to remain compliant, pedorthists must
record and measure their patient’s feet on a yearly basis. He also advised
documenting the method of treatment.

“Whether it is sizing shoes or orthoses, CMS wants to know the
method of your treatment,” Mason said.

In-person visits are required for initial evaluation or fitting.
According to Mason, this is to eliminate mail orders.

While all these compliances seem restraining, Mason believes most
pedorthists will adjust appropriately.

“If you are doing your job, chances are you are going to fulfill
all of these requirements,” Mason said. “Review your products and
make sure they are in compliance with these standards. — by Anthony

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As practitioners, we are responsible for both clinical knowledge as well
as policy knowledge. It is equally important to manage both of these areas
professionally. Thorough, accurate and relevant documentation has been a
responsibility of O&P for a long time. The recent changes and
clarifications to the pedorthic policies further illustrate the trend towards
responsible documentation. The key factor continues to require telling the
‘why’ along with the ‘what.’ For example, not all diabetics
have the medical necessity for diabetic shoes. Clinical charts should be able
to tell ‘why’ the diabetic patient required use of the diabetic shoe

  Jonathan Naft
  Jonathan Naft

According to the longstanding Medicare diabetic certification statement,
one or more of the six listed conditions satisfy the policy requirement for the
diabetic shoe benefit. As clinicians, it must be clear, from our notes,
regarding the patient’s condition that has been selected on the diabetic
certification statement.

Moreover, the CMS Physician Documentation Requirement states: “It
is important to note that even though you may complete and sign a form
attesting that all of the coverage requirements have been met, there also must
be documentation in your records to indicate that you are managing the
patient’s diabetes and that one of the conditions listed in 3a-f is
present. If requested by a supplier, you must provide copies of those

— Jonathan Naft, CPO
President, Geauga
Rehabilitation Engineering and O&P Business News Practitioner
Advisory Council member

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