Legislation has passed re-confirming that the orthotist's and prosthetist's clinical notes as part of the patient's medical record. This seems to be a small win for O&P clinicians that restores some credibility to their clinical notes.
". 50402. ORTHOTIST’S AND PROSTHETIST’S CLINICAL NOTES AS PART OF THE PATIENT’S MEDICAL RECORD. (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).”.
These changes present many questions in my mind and also some points that are clear. The first thing that is noteworthy is that the legislation states "part of the individual's medical record" and "to support documentation of eligible professionals." This does not indicate that the clinician's record will suffice independently as reasonable for supporting medical necessity. This does not diminish the need for provider's to obtain quality physician records to support medical necessity. In my mind, this simply suggests that we are restoring credibility to clinician records and we will include these records in the medical necessity determination. Provider's still must ensure to obtain all other necessary medical necessity documentation. From this perspective, I see little change in the recommendations that I would make to my provider's in terms of documentation but I do believe that this legislation takes a necessary step in restoring some credibility to the profession, which is a highly-trained profession deserving of credibility.
Questions that present in my mind are... timelines? How soon will we see this change in respect to claim reviews, audits, appeals? Will it really have any change since realistically our records were already accepted to "support" physician medical records?
What are your thoughts?