Last month in Part 1 of Compliance Tips to Prevent Claim Denials we reviewed how physicians and qualified healthcare professionals (QHPs) should (1) meticulously document the medical necessity of and (2) carefully write orders for specific durable medical equipment (DME) and supplies needed by patients with chronic wounds. In this month's installment, we will answer some frequently asked questions that apply to all claims submitted to the DME Medicare Administrative Contractors (MACs). Physicians and QHPs should incorporate these compliance tips into their documentation and orders for all equipment and supplies they wish for DME suppliers to provide for their Medicare patients. The notice in the Figure summarizes the importance of physician and/or QHP orders and medical necessity documentation when their patients need DME equipment and supplies.
Q: Is it true that physicians and QHPs must submit detailed written orders (DWOs) for all DME equipment and supplies before the DME supplier can submit claims to Medicare?
A: Yes, the physician or QHP ("treating physician") who provides direct care to the beneficiary for the condition(s) related to the DME equipment and/or supplies must submit a DWO for all DME equipment and supplies. Someone other than the physician/QHP may complete the order for the item unless statue, manual instructions, the contractor's local coverage determination (LCD), or policy articles specify otherwise. However, the treating physician must review the content and sign and date the document.
Q: What must the DWO contain?
A: It must contain
* beneficiary's name;
* prescribing physician's name;
* date of the order;
* all items, options, or additional features that are separately billed or require an upgraded code; the description can be either a narrative description (eg, lightweight wheelchair base), a Healthcare Common Procedure Coding System code or code narrative, or a brand name/model number;
* prescribing physician's signature; and
* signature date, if applicable.
For items provided on a periodic basis, including drugs, the written order must include
* item(s) to be dispensed;
* dosage or concentration, if applicable;
* route of administration, if applicable;
* frequency of use (must contain detailed instructions for use and specific amounts to be dispensed); NOTE: orders that state "PRN" or "as needed" are not sufficient to justify payment for the equipment/supplies;
* duration of infusion, if applicable;
* quantity to be dispensed; and
* number of refills.
Q: Under what circumstances must the DME supplier receive a new DWO from the physician or QHP?
A: A new order is required
* for all claims for purchases or initial rentals;
* if there is a change in the order for the accessory, supply, drug, etc;
* on a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy;
* when an item is replaced; and
* when there is a change in the supplier, and the new supplier cannot obtain a copy of a valid order and documentation from the original supplier.
Q: Can a DME supplier deliver equipment and/or supplies before the physician/QHP provides a DWO?
A: Yes, most equipment and supplies may be delivered upon request of a dispensing order that may be verbal or written. Some dispensing orders are required by statute and/or Centers for Medicare & Medicaid Services (CMS) regulations to have specific elements and other requirements. Those requirements can be found in specific LCDs and articles. When items are delivered based on a dispensing order, the DME supplier must obtain the DWO before submitting the claim to Medicare. The dispensing order must contain
* description of the item;
* beneficiary's name;
* prescribing physician's name;
* date of the order; and
* prescribing physician's signature (if a written order) or DME supplier signature (if verbal order).
Q: Is a DWO sufficient documentation of medical necessity for DME equipment and/or supplies?
A: No, it is not considered part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included in the DWO but must be corroborated by information contained in the medical record. NOTE: The medical record is not limited to treating physician/QHP office records but may include records from other types of facilities and healthcare professionals. CAUTION: Records from suppliers or healthcare professionals with a financial interest in the DME supplier claim outcome are not considered sufficient for determining that an item is reasonable and necessary.
Q: For ongoing supplies and rented DME items, what information must be in the beneficiary's medical record to support that the item remains reasonable and necessary?
A: Information used to justify continued medical need must be timely for the DME supplier's date of service. Any of the following documentation justifies continued medical need:
* a recent order for refills by the treating physician/QHP,
* a recent change in order,
* a properly completed certificate of medical necessity (CMN) or DME information form (DIF) with an appropriate length of need specified, and
* timely documentation in the beneficiary's medical record showing usage of the item. NOTE: Timely documentation is defined as a record in the preceding 12 months unless otherwise specified in the DME MAC's LCDs and/or Articles.
Q: I understand that DME suppliers are responsible for monitoring use of DME rental equipment and ongoing supplies and that they must discontinue billing Medicare when these items are no longer used by the beneficiary. What documentation can prove continued use?
A: Beneficiary medical records or supplier records may be used Any of the following may serve as documentation:
* timely documentation in the beneficiary's medical record showing usage of the item, related option/accessories, and supplies; NOTE: Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the DME MAC's LCDs and/or Articles;
* DME supplier records documenting the request for refill/replacement of supplies in compliance with the DME supplier refill documentation requirements. This is deemed sufficient to document continued use for the base item, as well; and
* DME supplier records documenting beneficiary confirmation of continued use of a rental item.
Q: How long must a DME supplier keep documentation of DME equipment and supplies provided to Medicare beneficiaries?
A: 7 years from the date of service.
Q: Can the treating physician/QHP use signature and date stamps on dispensing orders or DWOs?
A: No, signature and date stamps are not allowed. Signatures must comply with the CMS' signature requirements.
Q: Have the DME MACs written a guidance document that helps coordinate the documentation requirements of physicians/QHPs and the DME suppliers?
A: Historically, general DME equipment and supply documentation requirements have appeared within individual LCDs. Effective January 1, 2017, the DME MACs began including all general documentation requirements for physicians/QHPs and DME suppliers in a local coverage article, Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426). That article is now linked to all DME MAC LCDs and was last updated on May 7, 2018.
In addition, LCDs often contain unique documentation requirements. These requirements have been removed from all DME MAC LCDs whose effective date is on or after January 1, 2017, and can now be found in an LCD-related policy article that is linked to the applicable LCD. That article is entitled Policy Specific Documentation Requirements.
Therefore, physicians, QHPs, and DME suppliers should review (1) LCDs, (2) the LCD-related policy article, and (3) the Standard Documentation Requirements policy article to be sure they have all the relevant information necessary and applicable to the item(s) provided.