DME MAC Representatives Detail How to Avoid Errors in CMS Documentation

Incomplete and inaccurate medical records still account for most Medicare denials of O&P claims, but O&P facilities can improve their claims by following some guidelines and tips, according to a presentation at the American Orthotic and Prosthetic Association National Assembly.

Representatives from the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) shared common reasons for O&P claim denials and offered advice for avoidance of future denials. The representatives included Michael Hanna, provider relations senior analyst with DME MAC Region C; Stacie McMichel, Comprehensive Error Rate Testing (CERT) coordinator for provider outreach and education consultant with DME MAC Region B; Denise Winsock, outreach specialist with DME MAC Region A; and Michelle Wullstein, provider outreach and educational consultant with DME MAC Region D. In addition, Judie Roan, outreach specialist with DME MAC Region A, participated in the question and answer session.

Working with CERT

Hanna said in a review of errors from 2013 and 2014 claims, CERT found that in 2014 error rates for lower limb orthoses and lower limb prostheses increased by 27% for Region A and 35% by Region C, but decreased by 41% for Region B and 11% by Region D. The error breakdown showed medical records were the top reason for errors in lower limb orthosis claims, and replacement records were the top reason for errors in lower limb prostheses claims.

CMS uses the CERT program for claim submission, processing and payment. The CERT documentation contractor is Livanta, and the CERT review contractor is Advance Med. If a claim is missing information, then a CERT contractor will send a request for specific documentation to support the claim.

“If you do not follow-up and provide information to the CERT contractor, they will deny that claim,” Hanna said. The CERT contractor will send a barcoded sheet with the request letter. The barcoded sheet should be sent back with the documentation requested, he said.

Michael Hanna
Michael Hanna

CERT contractors do not want to see 10 years of documentation for something that happened last year, Hanna added: “Only send what is applicable for that claim, and the documents that the CERT contractor requested.”

O&P facilities can respond in four ways to a request for documentation: fax, electronic submission, mail or CD. Fax is the preferred method. Occasional extensions may be granted, but Hanna noted, “The CERT contractor typically grants extensions only in extreme circumstances,” such as a fire or flood at the facility.

If a CERT contractor detects an error on a claim, then the contractor will send the claimant an overpayment demand letter. To appeal, the claimant needs to file a redetermination.

“You have 120 days from the date on that demand letter to file a redetermination,” Hanna said. “If you file your redetermination with your appropriate DME MAC within 30 days, all activities recouping money will stop until the redetermination decision is made.” A standard redetermination template is available on all DME MAC websites, he said.

Ready to order

Orders should be provided by one of the following health care professionals: the patient’s treating physician; a nurse practitioner; a clinical nurse specialist; a physician assistant; or a podiatrist. The order can be provided via photocopy, facsimile image, electronic document or original “pen and ink” document. Winsock said many orders are denied due to illegibility.

“If you cannot read it, we cannot read it,” she said. “Make sure in that situation you get a new copy [from the person who wrote the order] before you submit your claims to Medicare.”

Presenters at the meeting noted that if an O&P practitioner receives a verbal dispensing order, this needs to be documented and followed up by a detailed written order. Documentation of a verbal dispensing order should include a description of the item, beneficiary’s name, physician’s name, date of the order date, start date and the signature of the practitioner supplying the device.


Detailed written orders must include the following: a description of the item; physician’s signature and date; beneficiary’s name; physician’s name; date of order date and start date, if start date is different; and options or additional features separately billed to Medicare.

If the practitioner is submitting a claim without an order, the claim should have an “EY” modifier to indicate there is no qualifying health care professional to provide the order. In addition, the practitioner should include his or her name and National Provider Identifier in box 17 of the claim. Claim lines with “EY” modifiers should be submitted separately from those without these modifiers.

A new order may be required when there is a change in the order; when medical policy dictates a regular requirement for new orders; when an item is replaced; when the “supplier” (practitioner) changes; or as required by state and federal law.

Denise Winsock
Denise Winsock

Winsock said O&P practitioners should take responsibility for their order error rates.

“This is something you can control. You can control this error and avoid a lot of what you have seen [by] ensuring all the elements are on the detailed written order before you do submit your claim,” she said.

Paint the picture with medical records

McMichel said medical records must reflect a need for the care being provided.

“We expect that the patient’s medical record paints the picture of what is transpiring [and] why you are providing this service, so we look to you to provide this information in the event of an audit,” she said. “We rely on the documentation to support what is being billed.”

Stacie McMichel
Stacie McMichel

CMS will accept medical records from any entity; however, only physician records can be used to support payment for the service or device. In fact, McMichel said CERT contractors will assume “if it has not been documented, it has not been done.”

She said the documentation needs to be completed as “a collaborative effort between the physician and the supplier,” referring to the O&P practitioner.

“We understand that [physicians] do not provide the product most of the time, so they do not know what components the patient may need, but from a clinical standpoint we need their records to support the diagnosis: any testing, any surgical procedures that have taken place. We look for that clinical piece from them and we look for your expertise in supplying the device or creating that for the patient,” McMichel said.

Physician documentation for a lower limb prosthesis should include functional limitations and capabilities, including ambulation; expected functional potential or differences; clinical course; prognoses; and past experience with related items. In addition, medical history relevant to the functional deficits or abilities should include comorbidities related to amputation, current or prior use of ambulatory assistance, musculoskeletal and neurological examinations and diagnosis-causing symptoms.

McMichel noted because the prosthetist is considered a supplier, his or her notes should corroborate those of the physician. For example, a prosthetist cannot list a patient as a “K3” if the physician documentation does not support that designation. A claim that lists a “K” modifier with no supporting information will not be approved.

Only physician notes can be used to justify payment. McMichel added physicians do not have to write in the codes, but their narrative description should support the code chosen by the prosthetist.

“We are looking for the diagnosis to support the way you code your claim,” she said.

Requirements for lower limb orthoses are the same for prostheses regarding the dispensing order, detailed written order and proof of delivery. Medical records must meet specific requirements for coverage criteria. For example, McMichel said, to prescribe an AFO, the medical record should show the beneficiary has weakness or deformity in the foot and ankle, requires stabilization for medical reasons and has the potential to benefit functionally from the device.


DMEPOS delivery guidelines

Hanna said proof of delivery for DME prosthetic and orthotic supplies (DMEPOS) is a supplier standard, and O&P offices should keep the records on file for 7 years.

“The proof of delivery is purely in your court. You control this document in its entirety,” he said.

The methods of proof of delivery include: direct to beneficiary, in which the day the beneficiary signs for the item is the date of service on the claim billed to CMS; shipping service, in which the shipping date should be the date of service; and delivery to skilled nursing facility, which is a combination of the first two methods and can be delivered personally or shipped. For a direct to beneficiary delivery, the supplier can date the form but beneficiaries need to sign it or have a representative sign it for them.

All proof of delivery forms should have a sufficient description of what was provided and the number of items. A description like “prosthetic foot” is not adequate, Hanna said.

One exceptional circumstance is the delivery of a DMEPOS item to a beneficiary staying in an inpatient facility, which occurs for fitting and training purposes. The item must be delivered within 2 days of discharge from the facility, and the supplier should bill the date of discharge as the date of service even though the item was delivered before discharge. An item with a date of service that occurred during an inpatient stay will be denied.

O&P repairs

O&P practitioners should remain aware of specific repair codes, according to Wullstein. Prosthetists should know L7510, repair of prosthetic device, repair or replace minor parts; and L7520, repair prosthetic device, labor component, per 15 minutes. The labor code may only be used for “time spent doing the actual repair or the adjustment,” Wullstein said. Time spent evaluating, taking measurements or assessing gait may not be coded for labor. Meanwhile, orthotists should know codes L4210, repair of orthotic device, repair or replace minor parts; and L4205, repair of orthotic device, labor component, per 15 minutes. The labor code may only be used for time involved in the actual repair or for medically necessary adjustments made more than 90 days after delivery. Orthotists may not use the labor code to account for time spent modifying a prefabricated item to fit the beneficiary or for adjustments made within 90 days after delivery.

Michelle Wullstein
Michelle Wullstein

Repair codes are general, so the practitioner needs to indicate in the record what the specific device is and which part is being repaired or replaced.

For a repair, the practitioner does not need to provide documentation for the initial medical need but does need to show continued medical need. In addition, the treating physician must show the item continues to be medically necessary. Examples include a recent (within the last 12 months) order for refills or a recent change in prescription.

Documentation from the supplier or the physician should explain the need for the repair: why it is necessary and what happened to the device.

Off-the-shelf vs custom-fitted orthoses

Wullstein reviewed the definition of off-the-shelf (OTS) orthoses, which are prefabricated; may or may not be supplied as a kit that requires some assembly; and require “minimal self-adjustment” as defined by CMS.

“Such an adjustment would be done by the beneficiary, caretaker or someone in your office who does not have specialized training and does not require the expertise of a certified orthotist to perform that adjustment. [Things] like adjusting the straps and closures [and] bending and trimming for a proper fit, those are all considered minimal self-adjustment for coding purposes,” she said.

Custom-fitted orthoses, as defined by CMS, have the same first two requirements as OTS orthoses but also require substantial modification “above and beyond what is typically done for off-the-shelf [orthoses]” for fitting at the time of delivery, Wullstein said.


“Just because an orthotist performs adjustments on a brace does not automatically qualify it as custom-fitted,” she added; rather, it should be a substantial adjustment that can only be made by a certified orthotist or someone with specialized training for custom-fitting services. The latter group includes physicians, treating practitioners (physician assistant, nurse practitioner or clinical nurse specialist), occupational therapists and physical therapists.

Documentation for both OTS and custom-fitted orthoses requires suppliers must provide the product specified by the ordering physician; ensure the physician’s medical record justifies the need for that type of product; uses a code that reflects the type of orthosis and the appropriate level of fitting; and include detailed supplier documentation justifying the selected code.

Wullstein noted many orthoses may have two possible codes — one for OTS and one for custom-fitted devices. She also said claims for orthoses are frequently denied due to inadequate documentation.

“We want to see documentation to help support the code that you have selected to bill on your claim. If you are billing custom-fitting, we want to know specifically what was done. Just indicating that you trimmed, bent or molded that item to fit that patient may not be sufficient,” she said. “We want to know why an item was trimmed, why it was bent, why it was molded, what specifically was done [and whether you used] special tools or techniques. The more specific, the better to support the actual code that you chose.”

The practitioner also needs to explain “why you as a professional needed to perform those modifications [and] why the beneficiary or someone else could not have done those adjustments.”

She added, “Be very, very detailed to help support the code that is going to be billed on the claim.”

More information on CERT errors and CMS documentation is available at – by Amanda Alexander

Disclosures: Hanna, McMichel, Roan, Winsock and Wullstein report no relevant financial disclosures.

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