[FRXTOMMY]

I received a scooter evaluation from an M.D. He used the "Dear Doctor" letter as an outline of sorts for his chart notes. (It is definitely a chart note printed from his electonic file).
The doctor addresses the elements in the letter and has ruled out all options leading up to the scooter in detail.
Should I be concerned that he used the letter in this manner? Or, should I consider it fortuante that all of the issues were addressed and dispense the scooter?

[bpowell]

I would not consider the "dear Dr" letter as the chart notes. There should be additional documentation that is backed up by the letter, specifically in the MD chart notes. Below is from the Medicare manual regarding documentation.

For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient’s diagnosis and other pertinent information including, but not limited to, duration of the patient’s condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient’s record. However, neither a physician’s order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).
See PIM, chapter 3, section 3.4.1.1, for additional instructions regarding review of documentation during pre- and post-payment review.

[FRXTOMMY]

To clarify, all of the information is on a chart note. He simply typed some of the bullet points from the letter in question format and answered the questions.

For example, here are 2 direct quotes from the note:

Can a manual wheelchair meet this patient's mobility needs to independently accomplish all MRADL's in a safe and timely fashion?
No, Using his upper body to operate a wheelchair would make him much more short of breath. He gets short of breath with any activity.

MRADL's he is unable to accomplish in a safe and timely fashion due to mobility limitations: feeding, bathing, grooming, dressing


The chart note is all of this type of notations. The info is there, but I am concerned that it may not pass an audit given the format.

Any advise?

[bpowell]

I really don't have much advise for you, sorry. Everything I have read on this and with past experience, as long as you "paint the picture" of the beneficiary's condition and you follow the guidelines with the order process, you should be fine. Also, some of the manufacturers will do a pre-audit of your information to see if what you have would survive a Medicare audit, you might try that?

[FRXTOMMY]

I appreciate your insight!