CMS Issues Instructions for DME MACs to Immediately Implement Provisions that Require the Recognition of Orthotist and Prosthetist Clinical Documentation as Part of the Medical Record

AOPA and its lobbying team have been pressing CMS from all levels, most recently including consultation with Trump Administration officials at the Office of Management and Budget, to formally implement the provisions of Section 50402 of the Bipartisan Budget Act of 2018 (Public Law 115-123) as it related to the prosthetist’s and orthotist’s clinical notes.

AOPA was encouraged bythe DME MAC notification 2-3 weeks ago where the DME MAC Medical Directors announced that they were ‘retiring’ the August 2011 “Dear Physician” letter on Lower Limb Prosthetics.

AOPA would like to share a recent letter from Alec Alexander, CMS’ Director of Program Integrity, that indicates that CMS “has issued instruction to the Durable Medical Equipment (DME) Medicare Administrative Contractors (MAC) to implement Section 50402 immediately.”

Section 50402 states:
‘‘(5) DOCUMENTATION CREATED BY ORTHOTISTS AND PROSTHETISTS.—For purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by an orthotist or prosthetist shall be considered part of the individual’s medical record to support documentation created by eligible professionals described in section 1848(k)(3)(B).’’.

Mr. Alexander’s letter is a clear assertion of CMS’ commitment to acknowledge immediate implementation of the new statutory provisions in Section 50402, accepting the orthotist and prosthetist clinical notes as part of the individual’s medical record as to “determining the reasonableness and medical necessity of orthotics and prosthetics” e.g., functional levels, identification of broken, damaged parts and their repair, and identifying components in a category included in a physician approved detailed written order. We also suggest that AOPA members consider including a copy of the letter with all claims they file.

We will continue to keep you informed of any developments in this important area.

The letter from Mr. Alexander and the DME MAC announcement regarding the retirement of the Dear Physician letter for lower limb prostheses may be viewed on AOPA’s website at

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Initial Report on TPE Program Suggests Positive Results

Noridian Healthcare Solutions, who serves as the Jurisdiction A and Jurisdiction D Durable Medical Equipment Medicare Administrative Contractor, has released results for its initial audits under the Target, Probe, and Educate (TPE) program in Jurisdiction D. The published results are only for four HCPCS codes selected for the TPE program, L4360, L4361, L4386, and L4387, which all describe walking boot style orthoses.

The results of the TPE audits are encouraging with an improper claim payment rate of 19{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4}. This improper payment rate represents a vast improvement over error rates under the previous audit system which consisted of a probe review followed by widespread pre-payment review. Improper payment rates under this program ranged from 66{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4} to 100{b3e9dd6b2a2b9b0b8877c781f3059c6a19b65fa453cdc02b99584f3fd07dbcf4} for walking boot style orthoses.

While the results did not discuss the reason for the significant reduction in the error rate, it is logical to conclude that the improvements are primarily due to the education efforts that are an integral part of the TPE program. The TPE program is designed to provide up to 3 rounds of audits with personalized provider education after each round that is designed to address the specific reasons for claim denial.

The results published by Noridian are certainly encouraging and AOPA will be monitoring the DME MAC websites for additional results from the TPE program.

The Noridian publication may be viewed at the following link.

AOPA’s Take. Where you go…….When you need to know!!!