Compliance advice offered to providers in the orthotic and prosthetic arena

There are high clinical documentation standards for orthotic and prosthetic (O&P) providers. Non-compliance with these documentation requirements can result in numerous adverse consequences for O&P providers, including: audits; recoupment of payments already received; loss of contracting and provider privileges; civil money penalties; loss of credentialing, certification, or licensure; the risk of getting on the Zone Program Integrity Contractor (ZPIC) radar, and exclusion from participation with any physician that accepts government funding, such as Medicare or Medicaid.

Understanding and applying compliance requirements in the O&P arena was the focus of a Health Care Compliance Association (HCCA) webinar offered by Tonja Wise, CHC, Corporate Compliance Manager, O&P Compliance Officer, Shriners Hospitals for Children International.

Wise’s presentation began by explaining why the O&P provider needs compliance and how O&P is different from other specialties. She then discussed the O&P provider’s obligations in the areas of documentation, provider notes, coding, and billing. Wise also noted the importance of the prescribing physician, who shares some of the documentation responsibility with the O&P provider. A summary of Wise’s major points of these topics include the following:

  • As a result of recent fraudulent activity and increased payment recoveries, O&P has become the new durable medical equipment (DME) when it comes to audits and scrutiny by the Office of Inspector General (OIG).
  • O&P suppliers that intend to bill Medicare (and Medicaid in most states) must be accredited. The Board of Certification/Accreditation (BOC) and the Association of Boards of Certification (ABC) both offer this service. Going through accreditation is good practice for ensuring that the organization meets the Medicare Supplier Standards and the accreditation standards.
  • Medical documentation must corroborate the O&P provider’s chart and justify the order written and device supplied. Documentation of the orders, delivery, use and care instructions, and safety are very specific.
  • Documentation requirements include a signed HIPAA acknowledgement; consents for treatment; a valid dispensing order prior to delivery; a signed, detailed written order prior to billing; a detailed delivery receipt; complete, comprehensive O&P provider notes; safety checks completed; and proof of patient care and instructions.
  • Provider notes should be complete, comprehensive, and compliant. This means each patient visit should have an independent, detailed note. The initial evaluation and the delivery visits are the most involved and will be the most important to the payor or auditor. These notes must outline all of the information necessary to support medical necessity.
  • It is the responsibility of the certified O&P provider to ensure that the appropriate Healthcare Common Procedure Coding System (HCPCS) codes are selected.
  • Know the federal requirements for the warranty period for O&P devices. CMS requires a 90-day warranty for all new devices. State Medicaid warranty periods may differ. The O&P provider does not need a new prescription for repairs if the provider delivered the device, unless major components are being replaced.
  • All bills should be reviewed for accuracy and consistency prior to submission. Confirm that diagnostic codes on all orders are consistent with the claim. Ensure all modifiers are included with the claim and are accurate.
  • Prescribing physicians are responsible for providing orders that meet CMS criteria for all O&P devices, documenting all medical necessity for the device being ordered, providing accurate diagnosis data (O&P providers cannot diagnose), and supplying any medical documentation necessary to support the O&P provider’s claim.


Wise believes that the best protection for an O&P provider is to have a robust compliance program in place to monitor coding, billing, medical necessity, and documentation. To ensure this compliance, she suggests that the O&P provider do the following:

  • Conduct annual compliance education.
  • Utilize access to O&P resources for guidance.
  • Be knowledgeable of federal, state and local requirements.
  • Be educated on payor requirements.
  • Read and understand the local coverage decisions (LCDs) and reference them frequently.
  • Be a self-auditor and audit frequently.
  • Ensure that any regulatory updates or major changes to O&P are communicated throughout the organization.

MedPAC votes to recommend recalculation of MA benchmarks

The Medicare Payment Advisory Commission (MedPAC) unanimously voted to recommend that the HHS Secretary modify the calculation of Medicare Advantage (MA) benchmarks. The recommended change, discussed at the January 12, 2017, MedPAC meeting, would increase spending between $750 million and $2 billion over one year and between $5 billion to $10 billion over five years. Mark Miller, executive director of MedPAC, suggested, however, that previous coding recommendations from the June 2016 report could offset the increased cost.

CMS sets the MA county benchmark based on the average risk-adjusted per capita Part A and Part B fee-for-service (FFS) spending in the county. While this calculation includes all beneficiaries in Part A or Part B, MA enrollees must be in both Part A and Part B. MedPAC policy analyst Scott Harrison noted that 12 percent of FFS beneficiaries are enrolled in Part A only, and Part A-only beneficiaries spend less than half than what those with Part A and Part B spend on Part A. This, he said results in an underestimate of FFS spending compared to MA spending, which leads, in turn, to an understatement of MA benchmarks.

To make calculations more reflective of MA enrollment, the members voted on a draft recommendation, which they also discussed at the December 2016 meeting, that the HHS Secretary should calculate MA benchmarks using FFS spending data only for beneficiaries enrolled in both Part A and Part B.

CMS already adjusts the rate calculation in Puerto Rico so that it is based on beneficiaries who are enrolled in both Part A and Part B. In the April 2016 Announcement of Calendar Year 2017 Medicare Advantage Capitation Rates and Medicare Advantage and Part D Payment Policies and Final Call Letter, CMS stated in response to a comment that it would consider expanding this Part A and Part B adjustment to all counties in the future.

At the same meeting, MedPAC also voted to recommend that the Secretary should require hospitals to add a modifier on claims for all surgical services provided at off-campus, stand-alone emergency department facilities. The modifier would allow Congress and CMS to track the growth of off-campus emergency departments, which are reimbursed at higher rates than urgent care centers.

Providers still have time to prepare for ICD-10, say experts

There is still time to prepare for International Classification of Diseases, Tenth Revision (ICD-10) before the October 1, 2015 implementation date, presenters emphasized during the MLN Connects National Provider Call, “Countdown to ICD-10.” In advance of the implementation, just over a month away, presenters discussed coding and documentation requirements, billing and reporting guidelines, and testing results.


CMS adopted ICD-10-CM (Clinical Modification) for diagnosis coding and ICD-10-PCS (Procedure Coding) for hospital inpatient procedure coding to replace ICD-9. CMS initially set an implementation date of October 1, 2013 (see Final rule, 74 FR 3328, January 16, 2009) but later extended it to October 1, 2014. Pursuant to section 212 of the Protection Access to Medicare Act (P.L. 113-93), CMS established October 1, 2015, as the final implementation date for ICD-10 (see Final rule, 79 FR 45128, August 4, 2014).

ICD-10 preparation

The ICD-10 Quick Start Guide outlines five steps for providers to prepare for ICD-10: (1) make a plan by assigning target dates for completing each step; (2) train staff on the fundamentals of ICD-10 and identify the top ICD-9 codes that the provider uses; (3) update processes, including updates of hard copy and electronic forms; (4) talk to vendors and health plans to confirm their readiness for ICD-10; and (5) test systems and processes to verify ICD-10 readiness.

Stacey Shagena, a technical advisor for CMS, described CMS’s four-pronged approach to testing for ICD-10 and noted that the national acceptance rate for acknowledgment testing ranged from 76 percent in November 2014 to a high of 91.8 percent in March 2015. No system errors were found in the July 2015 end-to-end testing, and according to CMS, “testing demonstrated that CMS systems are ready to accept ICD-10 claims.”


Sue Bowman, senior director, Coding Policy and Compliance, for the American Health Information Management Association, noted that the determination of which code set to use depends on the date of service, not the billing date. Claims for dates of service on or after October 1, 2015, must be coded in ICD-10, while claims for dates of service before October 1, 2015, must be coded in ICD-9. The date of service for inpatient facility reporting is the date of discharge. The claim submission date is irrelevant in the determination of which code set to use. MLN Matters SE1408 describes how to handle claims that span October 1.

The increased specificity of ICD-10 codes requires more detailed clinical documentation, according to Nelly Leon-Chisen, Director, Coding and Classification, for the American Hospital Association. She advised providers to assess their current documentation practices and resolve documentation gaps.

Transition flexibility

CMS is, however, offering some flexibility to physicians and other practitioners paid under the physician fee schedule who are transitioning to ICD-10. For 12 months after the ICD-10 implementation, if a valid ICD-10 code from the right family (i.e., the ICD-10 three-character category) is submitted, Medicare will process the code and will not audit based on specificity. In addition, for quality reporting completed for program year 2015, physicians and other eligible professionals (EPs) will not be subject to the Physician Quality Reporting System, value-based modifier, or meaningful use penalties during primary source verification or auditing related to additional specificity of the ICD-10 code as long as the physician/EP used a code from the correct family of codes. An EP will also not be subject to a penalty if CMS has difficulty calculating quality scores due to the transition.


Acting CMS Administrator Andy Slavitt announced that CMS is setting up and staffing an ICD-10 resource center, which will be operational in September, and named Dr. William Rogers as the ICD-10 ombudsman. The ombudsman, whose email address is, will be a “one-stop shop” for providers, said Slavitt.

The fiscal year 2016 ICD-10 code set is available from the Centers for Disease Control and Protection.

Highlight on North Carolina: NC ramps up for ICD-10, provides fun coding facts

NCTracks, a new multi-payer Medicaid Management Information System for the North Carolina Department of Health and Human Services (NC-DHHS) has used a “RAMP UP to ICD-10” project to assist provider organizations with the transition from ICD–9 to the ICD-10 code sets.

ICD-10 Background

On January 16, 2009, HHS posted a Final rule that would replace ICD-9 (International Classification of Diseases, 9th Revision, Clinical Modification) code sets for all Health Insurance Portability and Accountability Act (HIPAA) covered entities with ICD–10–CM (10th Revision, Clinical Modification) for diagnosis coding, and ICD–10–PCS (10th Revision, Procedure Coding System) for inpatient hospital procedure coding, effective October 1, 2013.

On August 24, 2012, HHS posted a Final rule that extended the compliance date to October 1, 2014. Congress voted to extend the October 1, 2014 ICD-10 implementation date for one year, until October 1, 2015.

The new ICD-10 code set provides a significant increase in the specificity of the reporting, allowing more information to be conveyed in a code.  The number of diagnosis/procedure codes is greatly expanded from about 17,000 to over 150,000 codes. Examples of the enhancements made with ICD-10 include:

  • Reporting of laterality (right vs. left designations), reflecting the importance of which side of the body or limb (e.g., left arm, left kidney, left eye) is the subject of the evaluation.
  • Restructured reporting of obstetric diagnoses. In ICD-9-CM, the patient is classified by diagnosis in relation to the episode of care. In ICD-10-CM, the patient is classified by diagnosis in relation to the patient’s trimester of pregnancy.

CMS has a webpage dedicated to the ICD-10 rollout. NCTracks also has a webpage with answers to frequently asked questions regarding ICD-10.


To help organizations prepare for ICD-10 implementation, NCTracks offered a series of topics intended to assist North Carolina providers in navigating the activities that needed to be done. RAMP UP stands for: Research, Assessment, Mapping, Process Improvement and Training, Update System(s) with Vendors, and Perform Testing. A brief description of each topic follows:

  • Research. A successful transition to ICD- 10 requires significant research and planning, including effective communication to stakeholders.
  • Assessment. The starting point for ICD-10 transition is an assessment to understand the role and location of ICD-9 codes across all systems, processes, policies and reports. Providers must identify business areas affected by ICD-10 and determine the level of support needed for successful transition.
  • Mapping. The process of evaluating and documenting the relationship between ICD-9 and ICD-10 code sets is a major aspect of preparing for ICD-10. While the General Equivalence Maps (GEMS) developed by CMS are a great starting point, for mapping they do not cover all of the potential ICD-9 to ICD-10 relationships, so additional analysis may be necessary. NCTracks has created a helpful crosswalk connecting the old ICD-9 codes to the new ICD-10 codes.
  • Process improvement and training. The move from ICD-9 to ICD-10 will affect not only computer systems, but business processes as well. Successful implementation will require evaluation and update of all aspects of provider business operations to coincide with the technical changes. This will include training to ensure the staff acquires the necessary skills and knowledge on the processes, procedures, policies, and system updates affected by the ICD-10 transition.
  • Update system(s) with vendors. The activities in research, assessment, mapping, and process improvement lead up to updating of computer system(s) for ICD-10. Part of updating computer systems involves vendor coordination to synchronize changes to inbound and outbound external interfaces.
  • Perform testing. Thorough testing ensures that business functions will continue normally throughout the transition. A rigorous testing methodology, documented test plan, and accurate test data are integral to achieving results that meet expectations.

North Carolina Ready for ICD-10 Launch

On April 30, 2014, NCTracks reported that it has completed 10 months of internal testing activities and recently started external testing with providers, which will continue through August 2015. It selected providers representing a diversity of practices, specialties and facilities.

According to NCTracks, system integration testing started in June 2014, and by November 2014, improvements had been made so that 100 percent of claims passed. In December 2014, NC-DHHS staff began user acceptance testing with CSC, the fiscal agent that manages NCTracks. This testing ran through mid-April 2015 using various scenarios. CSC ran selected transactions for professional, dental and institutional claims, representing a minimum of 10,000 claims. CSC converted all submitted ICD-9 codes to an ICD-10 equivalent using a crosswalk table, then compared and validated the results from the test against previous production claims.

Fun Facts

NCTracks has also posted some “ICD-10 Fun Facts Sheets” highlighting the greater specificity and unusual nature of some of the diagnosis and procedure codes coming with ICD-10: