Standard Documentation Requirements for All Claims Submitted to DME MACs

Many errors reported in Medicare audits are due to claims submitted with incomplete or missing requisite documentation. Consequently, the Durable Medical Equipment Medicare Administrative Contracts (DME MACs) have created guidance to assist Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers in understanding the information necessary to justify payment. The documentation requirements are compiled from Statutes, Code of Federal Regulations, Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs), CMS rulings and sub-regulatory guidance (CMS manuals), and DME MAC publications. This article sets out the general requirements that are applicable to all DMEPOS claims submitted to the DME MACs. Documentation must be maintained in the supplier's files for seven (7) years from date of service (DOS). ***IMPORTANT*** All Policy Specific Documentation Requirements are located in the LCD-related Policy Article, which is linked to the applicable LCD. It is important that suppliers review the actual LCD, the related Policy Article, and the Standard Documentation Requirements (SDR) article to be sure to have all of the relevant information necessary and applicable to the item(s) provided. Note: The information in the LCDs and/or related policy articles supersede this document. Where there are differences between the policies and this article, the LCDs and/or related policy articles shall take precedence. ORDERS GENERAL All claims for items billed to Medicare require a written order/prescription from the treating practitioner as a condition for payment. This written order/prescription is referred to as the Standard Written Order (SWO) (see below). “All claims” refers to all claims submitted for payment of purchases or rentals to Medicare Part B. The term “treating practitioner” is used throughout this document and except where specifically noted, refers to physician, as defined in section 1861(r) of the Social Security Act, or physician assistant (PA), nurse practitioner (NP), or clinical nurse specialist (CNS), as those terms are defined in section 1861(aa)(5) of the Social Security Act . The name and National Provider Identifier (NPI) of the treating practitioner on the order/prescription for the item or service shall be used on the claim submitted to the DME MAC. The order/prescription shall be kept on file and made available upon request. Items dispensed and/or billed that do not meet these order/prescription requirements and those below must be submitted with an EY modifier added to each affected Healthcare Common Procedure Coding System (HCPCS) code. Certain items require an order based on statute (e.g., therapeutic shoes for diabetics, oral anticancer drugs, and oral antiemetic drugs which are a replacement for intravenous antiemetic drugs). In such instances, if statutory requirements related to the order are not met, the claim will be denied as not meeting the benefit category. For DMEPOS items other than PMDs, someone other than the treating practitioner may complete certain required elements of the SWO; however, the SWO must be signed by the treating practitioner. Prescribing of DMEPOS is limited by Medicare regulations and by the treating practitioner’s respective scope of practice as determined by the state wherein they practice. Chiropractors are not permitted to prescribe DMEPOS items. NEW ORDER REQUIREMENTS A new order/prescription is required: For all claims for purchases or initial rentals; If there is a change in the DMEPOS order/prescription ( e.g., quantity) ; On a regular basis (even if there is no change in the order/prescription) only if it is so specified in the documentation section of a particular medical policy; When an item is replaced; When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order/prescription for the DMEPOS item from the transferring supplier. STANDARD WRITTEN ORDER (SWO) A SWO must be communicated to the supplier prior to claim submission. For certain items of DMEPOS, a written order is required prior to delivery (WOPD) of the item(s) to the beneficiary (see below). A SWO must contain all of the following elements: Beneficiary's name or Medicare Beneficiary Identifier (MBI) Order Date General description of the item The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number 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 require an upgraded code (List each separately). For supplies – In addition to the description of the base item, the DMEPOS order/prescription may include all concurrently ordered supplies that are separately billed (List each separately) Quantity to be dispensed, if applicable Treating Practitioner Name or NPI Treating practitioner's signature Signatures must comply with the CMS signature requirements outlined in the Medicare Program Integrity Manual (CMS Pub.100-08), Chapter 3, Section 3.3.2.4. Signature and date stamps are not allowed. Upon request by a contractor, DMEPOS suppliers must provide documentation of the completed SWO. 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. However, the medical record must still contain all of the required SWO elements. WRITTEN ORDERS PRIOR TO DELIVERY (WOPD) A WOPD is a completed SWO that is communicated to the DMEPOS supplier before delivery of the item(s). Pursuant to Final Rule 1713 (84 Fed. Reg Vol 217), CMS may select DMEPOS items appearing on the Master List of DMEPOS Items potentially subject to a Face-to-Face Encounter and WOPD requirement and include them on a Required List. The Required List will be comprised of: Statutorily required DMEPOS items such as Power Mobility Devices (PMDs); and Additional DMEPOS items selected by CMS appearing on the Required List. Items appearing on the Required List are subject to the face-to-face encounter and WOPD requirements. CMS and the DME MACs will post on their websites the Required List of the selected HCPCS codes, once published through the Federal Register Notice, and the Required List will be periodically updated. The current required Face-to-Face Encounter and Written Order Prior to Delivery List is available here . Note that the face-to-face encounter and WOPD requirements are statutorily required for PMDs, and in accordance with this statutory obligation, both will continue to be required, and will be included in any future publications of the Required List. The date of the WOPD shall be on or before the date of delivery. A WOPD must be completed within six (6) months after the required face-to-face encounter. For PMDs, following the face-to-face encounter, the treating practitioner must complete the WOPD of the item pursuant to 1834(a)(1)(E)(iv). The term “treating practitioner” for PMDs is defined as both physicians (defined in section 1861(r)(1) of the Social Security Act) and non-physician practitioners (i.e., PA, NP, and CNS); defined in section 1861(aa)(5) of the Social Security Act. Upon request by a contractor, DMEPOS suppliers must provide documentation of the completed WOPD. DOCUMENTATION REQUIREMENTS GENERAL There are numerous CMS manual requirements, reasonable and necessary (R&N) requirements, benefit category, and other statutory and regulatory requirements that must be met in order for payment to be justified. In the event of a claim review, a DMEPOS supplier must provide sufficient information to demonstrate that the applicable criteria have been met thus justifying payment. Before submitting a claim to Medicare, the DMEPOS supplier must have on file an SWO, a WOPD (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. The supplier should also obtain as much documentation from the patient's medical record in order to assure themselves that coverage criteria for an item have been met. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice of Noncoverage (ABN) of possible denial has been obtained. CMS requires that in the event of an audit, the MACs, CERT, SMRC, Recovery Auditors, and UPICs shall determine that an item/service is correctly coded. The supplier must have on file a description of items provided to the beneficiary in sufficient detail to determine the accuracy of claims coding including a description of the items(s) delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number. Reimbursement shall be based on the specific utilization amount that is supported by contemporaneous medical records. Documentation must be maintained in the supplier's files for seven (7) years from DOS. If the Medicare qualifying supplier documentation is older than 7 years, proof of continued medical necessity of the item or necessity of the repair can be used as the supporting Medicare qualifying documentation. REASONABLE AND NECESSARY CRITERIA (R&N) CMS National Coverage Determinations (NCDs) and contractor Local Coverage Determinations (LCDs) describe the requirements that must be met for an item to be considered R&N. These R&N criteria are often referred to as medical necessity. MEDICAL RECORD DOCUMENTATION In the event of a claim review, information contained directly in the contem

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