Suppliers need to recognize that receiving Medicare payment depends on their obtaining and retaining sufficient documentation to establish the medical necessity of claimed items and services. The AMA does not directly or indirectly practice medicine or dispense medical services. Applications are available at the AMA Web site, http://www.ama-assn.org/ama. If this is a U.S. Government information system, CMS maintains ownership and responsibility for its computer systems. 1060 (E.D. Standard Documentation Checklists. You may also contact AHA at ub04@healthforum.com. The documentation requirements are compiled from Statutes, Code of Federal Regulations, Centers for Medicare and Medicaid Services (CMS) manuals, and DME MAC publications. Wheelchair Documentation Requirements for Medicare 1) RX – Wheelchair (standard or lightweight) Must include: wheelchair or light wt w/c, diagnosis, length of need,hgt and weight and signed /dated by doctor (no stamps allowed) 2) No fee schedules, basic unit, relative values or related listings are included in CPT. CMS published specific “conditions for payment” for power mobility devices (PMDs), such as power wheelchairs and power-operated vehicles or scooters. “Call to Action – Health Reform 2009,” Nov. 12, 2008,finance.senate/gov/healthreform2009/home. American Medical Association. AS USED HEREIN, "YOU" AND "YOUR" REFER TO YOU AND ANY ORGANIZATION ON BEHALF OF WHICH YOU ARE ACTING. Medicare will review the information to make sure that you’re eligible and meet all requirements for the item. Joint DME MAC Publication. Detailed product description 6. Further, upon request, a supplier must “submit additional documentation to CMS or its agents to support and/or substantiate the medical necessity of the power mobility device.”[18]. It noted that a CMN is designed to record certain information to help determine whether DME is medically reasonable and necessary. [3]. The Court found that section 1834(j)(2) of the Social Security Act, pertaining to CMNs, cannot be read as limiting the statutory requirement that no Medicare payment may be made for items and services not medically reasonable and necessary.[12]. General Documentation Requirements Checklist - Printable Version [PDF], Last Updated Tue, 05 Jan 2021 16:04:53 +0000. Suppliers must still include a narrative description on the claim explaining the reason why the equipment must be replaced and are reminded to maintain documentation indicating that the DMEPOS was lost, destroyed, irreparably damaged or otherwise rendered unusable … The U.S. Supreme Court’s denial of review in the Maximum Comfort case resolves the legal debate about whether a CMN may be the sole basis for determining Medicare coverage and payment of expensive DME. Most of the calls we receive are regarding the tedious “application and supporting documentation” required to apply for the DME Medicare Provider Number. Determine if DME suppliers meet documentation requirements for prior authorization for power wheelchairs. Requirements of New Orders New order is required when: • For all claims for purchases or initial rentals; • If there is a change in the DMEPOS order/prescription e.g. This principle was reinforced by the CMS regulations issued in 2006 and the program guidance issued in 2008. Alexandria, VA 22315. However, because the … The CMS WILL NOT BE LIABLE FOR ANY CLAIMS ATTRIBUTABLE TO ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION OR MATERIAL CONTAINED ON THIS PAGE. Sign up for regulatory updates, compliance insights and industry best practices from our Compliance experts. These checklists include the documentation required for payment and retention of that payment in the event of a review by entities looking at documentation today and in the future. OIG Semi-Annual Report, April 1, 2008 – Sept. 30, 2008, issued Dec. 3, 2008, available at www.oig.hhs.gov/publicatoins/doc/semiannual/2008/semiannual_fall2008. This Agreement will terminate upon notice to you if you violate the terms of this Agreement. Therefore, Maximum Comfort remained liable for the assessed overpayments. Suppliers are reminded to review the Local Coverage Determination (LCD) and Policy Article for specific documentation guidelines. Three courts of appeals have now affirmed the principle that supporting medical documentation, in addition to a CMN, may be required to establish Medicare coverage.[23]. Enforcement of Medicare’s documentation requirements has become more stringent, and it’s affecting healthcare professionals and patients. Properly documenting DME orders is crucial for reimbursement. By becoming knowledgeable about Medicare regulations and program guidance, and properly training and informing employees, suppliers will be taking steps to ensure that timely payment is received for DME furnished to program beneficiaries. Paid for by the Department of Health & Human Services. Clinical Documentation Required for Wounds. 5911 Kingstowne Village Parkway [1]. But opting out of some of these cookies may have an effect on your browsing experience. Dissatisfied with the ALJ decisions, CMS asked the U.S. Department of Health and Human Services’ (HHS) Medicare Appeals Council to undertake an “own motion” review. The ADA is a third-party beneficiary to this Agreement. This product includes CPT which is commercial technical data and/or computer data bases and/or commercial computer software and/or commercial computer software documentation, as applicable which were developed exclusively at private expense by the American Medical Association, 515 North State Street, Chicago, Illinois, 60610. PT/OT Evaluation (recommended but not required) 3. The documentation requirements are compiled from Statutes, Code of Federal Regulations, Centers for Medicare and Medicaid Services (CMS) manuals, and DME MAC publications. II. Sign up for our weekly newsletter to stay up-to-date on regulatory updates, compliance insights and industry best practices. IF YOU DO NOT AGREE WITH ALL TERMS AND CONDITIONS SET FORTH HEREIN, CLICK ABOVE ON THE LINK LABELED "I Do Not Accept" AND EXIT FROM THIS COMPUTER SCREEN. If you choose not to accept the agreement, you will return to the Noridian Medicare home page. THE LICENSES GRANTED HEREIN ARE EXPRESSLY CONDITIONED UPON YOUR ACCEPTANCE OF ALL TERMS AND CONDITIONS CONTAINED IN THESE AGREEMENTS. For more information: CR 11104 (PDF) (Implementation date April 22, 2019) DMEPOS order requirements The Council rejected the supplier’s arguments that the Social Security Act establishes the CMN “as the sole mechanism for establishing coverage of DME” and that the Medicare program cannot impose additional documentation requirements for evaluating whether any claimed DME is covered.[5]. The Supreme Court’s action ended decade-long Medicare payment dispute. For DME to be covered by Medicare, the medical records must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items claimed. Any cookies that may not be particularly necessary for the website to function and is used specifically to collect user personal data via analytics, ads, other embedded contents are termed as non-necessary cookies. Two separate ALJ decisions were subsequently issued reversing both carrier overpayment assessments. A physician or treating practitioner must conduct a face-to-face examination of the beneficiary for the purpose of determining the medical necessity of a PMD as part of the overall treatment plan. var pathArray = url.split( '/' ); • Medical documentation supporting the need. This booklet explains Original Medicare coverage of DME and what you might need to pay. CPT codes, descriptions and other data only are copyright 2002-2020 American Medical Association (AMA). “CMS Enhances Program Intgrity Efforts To Fight Fraud, Waste and Abuse in Medicare,” Oct. 6, 2008,available at http://www.cms.hhs.gov/apps/media,press/release.asp?Counter=3291&intNumPerPage=10&checkDate=&checkKey=&srchType=1&numDays=3500&srchOpt=0&srchData=&keywordType=All&chkNewsType=1%2C+2%2C+3%2C+4%2C+5&intPage=&showAll=&pYear=&year=&desc=false&cboOrder=date. Upon request by a contractor, DMEPOS suppliers must provide documentation of the completed SWO. The AMA disclaims responsibility for any consequences or liability attributable to or related to any use, non-use, or interpretation of information contained or not contained in this file/product. The claimed DME was determined to be covered by Medicare because the supplier reasonably relied on CMNs signed by the physicians who ordered the equipment. Additional clinical documentation is required in order for NPWT to be covered by Medicare and most insurance companies and will vary depending on the type of wound that is being treated. The AMA is a third-party beneficiary to this license. According to the Council, no legal support exists for the supplier’s proposition “that the primary purpose of the CMN is to eliminate the need for any supporting medical documentation to establish medical necessity.”[6]. In other words, almost 30 percent of the DME claims reviewed were erroneously paid by the Medicare program. Effective June 5, 2006, the following requirements were imposed: The regulations state that a supplier “may not dispense a PMD to a beneficiary until the PMD prescription and the supporting documentation have been received the physician or treating practitioner who performed the face-to-face examination of the beneficiary.”[17]. Making copies or utilizing the content of the UB-04 Manual or UB-04 Data File, including the codes and/or descriptions, for internal purposes, resale and/or to be used in any product or publication; creating any modified or derivative work of the UB-04 Manual and/or codes and descriptions; and/or making any commercial use of UB-04 Manual / Data File or any portion thereof, including the codes and/or descriptions, is only authorized with an express license from the American Hospital Association. at 18. More recently, CMS issued program guidance for suppliers on documentation requirements for obtaining Medicare coverage and payment of DME. The supplier then requested federal court review. Understanding Documentation Requirements: •Goal: o Gain a better understanding of the documentation requirements for the Medicare Therapeutic Shoe Program. On January 1, 2020, new rules took effect governing written orders for all durable medical equipment, prosthetics, orthotics and supplies (DMEPOS). Applications are available at the American Dental Association web site, http://www.ADA.org. Based on its review of a sample of claims, the carrier determined the supplier had failed to furnish documentation demonstrating that the claimed power wheelchairs were medically reasonable and necessary. End users do not act for or on behalf of the CMS. On November 12, 2008, Senator Max Baucus, Chairman of the Senate Finance Committee, issued a “health care reform blueprint” that includes five principles for “preventing [health care] fraud, waste, and abuse before they happen, and aggressively detecting them when prevention fails.”[25]. Note: As outlined in the Medicare Benefit Policy Manual Chapter 20, Section 10.2 Coverage Table for DME Claims. This article sets out the general requirements that are applicable to all DMEPOS claims submitted to the DME … You also have the option to opt-out of these cookies. View documentation checklists created to help suppliers ensure all applicable documentation is readily available as part of Medicare claims payment and processing activities. Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. Suppliers also need to be cognizant of the current political environment regarding health care reform. The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. FOURTH EDITION. The scope of this license is determined by the AMA, the copyright holder. ; Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) All items billed to Medicare require a prescription from the treating practitioner as a condition of payment. AMA Disclaimer of Warranties and Liabilities CMS Acting Administrator Kerry Weems told attendees at an American Health Lawyers Association (AHLA) conference that the agency was going to “zero in” on Medicare fraud involving the highest paid DME suppliers and the highest billed equipment and supplies, including power wheelchairs.[2]. Visit our sister company Compliance Resource Center for custom tools and services, designed to meet your compliance program needs. The Medicare Appeals Council concluded that the supplier had claimed Medicare payment with only a CMN as support, so the equipment was not covered by Medicare. Maximum Comfort v. Leavitt, 512 F.3d 1081 (9th Cir.,2007). Documentation, including pertinent portions of the beneficiary’s medical records (e.g., history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans), supporting the medical necessity of the prescribed PMD must be furnished to the supplier within 45 days of the examination.. This site uses cookies and other tracking technologies to assist with navigation and your ability to provide feedback, analyze your use of our products and services, assist with our promotional and marketing efforts, and provide content from third parties. *DME must be for use in patient's residence other than a health care institution. Note: If your plan leaves Medicare and you’re using medical equipment like oxygen or a wheelchair, call the phone number on your Medicare Advantage Plan card and ask about DME coverage options. Subject to the terms and conditions contained in this Agreement, you, your employees, and agents are authorized to use CDT only as contained in the following authorized materials and solely for internal use by yourself, employees and agents within your organization within the United States and its territories. The U.S. Supreme Court recently denied review in a case, reaffirming the long-standing Medicare principle that suppliers must be able to demonstrate the medical necessity of durable medical equipment (DME), such as power wheelchairs and scooters, provided to beneficiaries to receive payment. For each … Any questions pertaining to the license or use of the CDT should be addressed to the ADA. IF YOU ARE ACTING ON BEHALF OF AN ORGANIZATION, YOU REPRESENT THAT YOU ARE AUTHORIZED TO ACT ON BEHALF OF SUCH ORGANIZATION AND THAT YOUR ACCEPTANCE OF THE TERMS OF THESE AGREEMENTS CREATES A LEGALLY ENFORCEABLE OBLIGATION OF THE ORGANIZATION. This position is consistent with the Medicare statutory requirement that “[n]o payment shall be made to any provider of services or other person under [Medicare] unless there has been furnished such information as may be necessary in order to determine the amounts due such provider or other person.”[24]. The supporting documentation must include subjective and objective, beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered. See In the case of the Scooter Store, available at www.hhs.gov/dab/macdecisions. Health Lawyers Weekly, Vol. On June 30, 2004, a U.S. district court reversed the Medicare Appeals Council and held that a completed CMN is the only documentation needed to establish the medical reasonableness and necessity of claimed DME.[8]. In 1996, CMS revised the regulations governing Medicare coverage and payment for DME. The Court also noted that appeals courts in two other circuits had decided in a similar fashion that the statute does not preclude the Medicare program from requiring additional documentation, beyond the CMN, to establish the medical necessity of claimed DME. This article sets out the general requirements that are If your doctors or suppliers aren’t enrolled, Medicare won’t pay the claims submitted by them. You agree to take all necessary steps to ensure that your employees and agents abide by the terms of this agreement. This article sets out the general requirements that are applicable to all DMEPOS claims submitted to the DME MACs. There are times in which the various content contributor primary resources are not synchronized or updated on the same time interval. Documentation Requirements for Physicians Who Order DMEPOS. The Medicare Program Integrity Manual was revised, effective March 1, 2008, and now provides: The HHS Office of Inspector General (OIG) has identified ongoing problems with Medicare payment of DME claims. [25]. Medicare and Medicaid Certification Letters . Compliance Program Design & Implementation, Compliance Program Effectiveness Evaluation, Durable Medical Equipment (DME) Documentation Required for Medicare Payment. VI, Issue 39, Oct. 10, 2008.Other equipment to receive heightened review include continuous positive airway pressure devices(CPAP), oxygen equipment, glucose monitors, and test strips. In those limited instances in which the treating practitioner is also the supplier and is permitted to furnish specific items of DMEPOS and fulfill the role of the supplier in accordance with any applicable laws and policies, a SWO is not required. This article discusses these issues further. The Court found that “Congress…established that any and all information required from suppliers to make a medical necessity determination must be contained in a CMN.”[10]. If the encounter is performed via telehealth, the requirements for telehealth services and payment for telehealth services must be met. The OIG issued a report in August 2008 regarding an audit of CMS’ medical review of DME claims paid by Medicare in fiscal year 2006. It recommended that, in reviewing DME claims, “CMS obtain all medical records (including, but not limited to, physician’s records) for DME claims and contact the beneficiaries named on high-risk claims.”[21]. Specific signature requirements found in NCDs, LCDs or other CMS manuals supersede the instructions in CR9225. This documentation must be retained by the supplier and furnished to CMS or a contractor upon request.