Recently, each of the four DME MAC contractors has published a revised version of the Dear Physician letter regarding artificial limbs. The revised version of the letter states that the Dear Physician letter is being retired due to pending guidance from the Centers for Medicare and Medicaid Services (CMS) on potential program changes that may be necessary to implement the recently passed legislation that requires recognition of O&P practitioner notes as part of the patient’s medical record.
The Dear Physician letter for artificial limbs, originally published in August, 2011, fundamentally changed how Medicare claims for artificial limbs were processed. Prior to the 2011 Prosthetic Dear Physician letter, practitioner notes were generally accepted as being valuable when making claim payment decisions. The Dear Physician letter made it clear that for Medicare purposes, “it is the treating physician’s records, not those of the prosthetist’s, which are used to justify payment.” This statement, and the overall tone of the Dear Physician letter lead to years of frustration where the clinical notes of qualified, educated, certified, and often licensed prosthetists, were simply ignored during the claim review process. This exclusion of valuable clinical information lead to higher claim denial rates and unacceptable delays in the appeal process.
With the February, 2018 passage of legislation that now requires documentation created by orthotists and prosthetists to be considered part of the patient’s medical record for medical review purposes, the statement quoted above and other parts of the Dear Physician letter are no longer consistent with the law. The DME MACs have acknowledged this and have decided to retire the 2011 Dear Physician letter for artificial limbs until they receive further guidance from CMS.
While the retirement of the Dear Physician letter does not mean that the DME MACs will no longer require physician documentation to support claims for artificial limbs, it is a clear indication that they acknowledge and understand that the provisions of the original Dear Physician letter are no longer consistent with the law and therefore can no longer be used as the sole justification for denying a Medicare claim. It also indicates that the diligent AOPA efforts to convince CMS to provide guidance on this issue to their DME MAC contractors. While AOPA does not know what that eventual guidance will be, it is clear that CMS is aware of the legislation and intends to provide guidance to the DME MACs regarding the role of O&P practitioner notes in the medical review process.