Throughout 2018, Payment Strategies discussed a variety of ways to prevent claim denials, which often lead to patients not receiving supplies and equipment they need to manage their skin and wound/ulcer conditions at home. By the time readers finished updating their knowledge about the order requirements and reviewing the LCDs and Articles that are pertinent to their business, they probably came to the conclusion that the order requirements were not consistent. And they were correct! Some equipment and supplies used at home required a detailed written order; others required a five-element order (written order prior to delivery [WOPD]), a seven-element order, or a detailed product description. Therefore, physicians and QHPs often found it difficult to remember which elements to include in their orders for the various products that they ordered for home use.
On January 1, 2020, this author was very excited when the DME Medicare administrative contractors (MACs) updated their Local Coverage Article (LCA): Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)1 to help reduce provider burden. This updated LCA implemented a standard written order (SWO) format that physicians and QHPs can follow for equipment and supplies covered for use in the home.
The new SWO requires six elements:
1. Beneficiary's name or Medicare Beneficiary Identifier
2. Order date
3. General description of the item
a. The description can be either a general description, a Healthcare Common Procedure Coding System (HCPCS) code, an HCPCS code narrative, or a brand name/model number
b. For equipment: In addition to the description of the base item, the SWO may include all concurrently ordered options, accessories, or additional features that are separately billed or that require an upgraded code (each listed separately)
c. For supplies: In addition to the description of the base item, the SWO may include all concurrently ordered supplies that are separately billed (each listed separately)
4. Quantity to be dispensed, if applicable
5. Treating practitioner name or National Provider Identifier
6. Treating practitioner's signature
a. Stamps are not allowed for signatures and dates
b. Signatures must comply with the CMS signature requirements2
All physicians and QHPs who write orders for equipment and supplies used by Medicare beneficiaries at home should ensure (1) that the six required elements of the new SWO are documented in each patient's medical record and (2) that an SWO is transmitted to each patient's DME, prosthetics/orthotics, and supplies (DMEPOS) provider.
The SWO must be dated before the DMEPOS supplier submits a claim to Medicare, unless the equipment/supply is subject to the WOPD requirements (see WOPD discussion below). For physicians and QHPs who are also DMEPOS suppliers, the six required elements of the new SWO must be documented in their patients' medical records, but a separate SWO is not required.
Now let's review what the updated LCA advises when a face-to-face encounter and a WOPD are required. To reduce provider burden, the SWO may act as the WOPD, but in this case the SWO must be transmitted to the DMEPOS supplier before the supplier delivers the item(s) to the Medicare beneficiary. To make it easy to know when a WOPD is required, the CMS and the DME MACs will post, on their websites, a master list of DMEPOS items that are subject to the face-to-face encounter and WOPD requirements. This list is expected to be published in the spring of 2020. Until then, the only item that requires a face-to-face encounter and a WOPD is a power mobility device. Once the master list is published, all items on the list will require a face-to-face evaluation by the physician or QHP within 6 months of the WOPD.
The updated LCA also outlines the requirements for "new" orders, which are required:
* For all claims for purchases or initial rentals
* If there is a change in the DMEPOS order (eg, quantity)
* On a regular basis (even if there is no change in the order)
* When an item is replaced
* When there is a change in the supplier, and the new supplier cannot obtain a copy of a valid order for the DMEPOS item from the transferring supplier
Because the updated LCA includes many vital documentation guidelines, this author highly recommends that all physicians and QHPs who order equipment and supplies covered for home use carefully read the entire LCA for a thorough review of topics such as
* Documentation of continued medical need
* Documentation of continued use
* Refill documentation
* Face-to-face encounter
* Certificate of Medical Necessity
* DME Information form
Physicians and QHPs who are also DMEPOS suppliers may also want to review the following topics in the LCA:
* Claim narratives
* Date spans on claims
* Proof of delivery
* Correct HCPCS coding
* Equipment retained from a prior payer
* Repairs and replacement
TEN ORDER REMINDERS
The new LCA simplifies the order requirements by reducing what needs to be documented in the medical record and on the SWO. In addition, one standard order is now required rather than several different order variations depending on the category of equipment and supplies. Physicians, QHPs, and DMEPOS suppliers should remember the following 10 facts when updating their order processes to take advantage of the simplified SWO requirements:
1. Physicians and QHPs who order equipment and supplies for the use of Medicare beneficiaries at home are responsible for documenting in each patient's medical record: the patient's diagnosis, the SWO, a certification of medical necessity (if applicable), a DME information form, and information for the use of specific modifiers or attestation statements. The physicians and QHPs are required to provide their documentation to the DMEPOS supplier.
2. If the information in the patient's medical record does not adequately support the medical necessity for an item, the DMEPOS supplier will be liable for the dollar amount involved unless the supplier obtained a properly executed Advance Beneficiary Notice of Noncoverage.
3. Separate SWOs are not considered part of the medicalrecord.
4. "PRN" orders are not sufficient to justify Medicarepayment.
5. Someone other than the treating practitioner may complete certain required elements of the SWO, but the SWO must be signed by the treating practitioner.
6. DMEPOS supplier-produced records, even if signed by the treating practitioners, and attestation letters (eg, letters of medical necessity) are not considered part of a medical record for Medicare payment purposes.
7. For supplies, "frequency" is no longer a required order element. For example, the Surgical Dressing LCA (A54563) was updated on January 1, 2020, and no longer requires the frequency of dressing change to be included in the SWO. However, the Surgical Dressing LCA does discuss frequency of dressing change in relation to required medical record documentation:3
For initial wound evaluations, the treating practitioner's medical record, nursing home, or home care nursing records must specify:
* The type of qualifying wound
* Information regarding the number and size of qualifying wounds being treated with a dressing,
* Whether the dressing is being used as a primary or secondary dressing or for some noncovered use (eg, wound cleansing)
* The type of dressing (eg, hydrocolloid wound cover, hydrogel wound filler, etc)
* The size of the dressing (if applicable)
* The number/amount to be used at one time
* The frequency of dressing change.
8. For drug orders, four elements are no longer required: dosage or concentration, frequency of administration, duration of infusion (if applicable), and number of refills.
9. Certain items require an order based on statute (eg, therapeutic shoes for patients with diabetes, oral anticancer drugs, and oral antiemetic drugs as a replacement for IV antiemetic drugs). In these instances, if statutory requirements related to the order are not met, the claim will be denied for not meeting the benefit category.
10. The DME MAC medical directors are working to update all LCDs and LCAs with the new SWO requirements. All physicians, QHPs, and DMEPOS suppliers should review the documents as soon as they are released.
REFERENCES