Article Detail - JA DME

To justify payment for Pneumatic Compression Devices (PCD) items, suppliers must meet the following documentation requirements:

• Standard Written Order (SWO)
• Beneficiary Authorization
• Proof of Delivery (POD)
• Continued Need
• Continued Use
• Certificate of Medical Necessity (CMS 846 CMN) (Required for dates of service prior to January 1, 2023)

Financial Attestation Statement - signed and dated stating the licensed/certified medical professional (LCMP) has no financial relationship with the supplier.

Medical records from treating practitioner must include enough information to support that coverage criteria have been met, including, but not limited to:

• The patient’s diagnosis and prognosis.
• Symptoms and objective findings, including measurements (meaning more than one) which establish the severity of the condition.
• The reason the device is required, including the treatments which have been tried and failed; and
• The clinical response to an initial treatment with the device.
  • The clinical response includes the change in pre-treatment measurements, ability to tolerate the treatment session and parameters, and ability of the patient (or caregiver) to apply the device for continued use in the home.
• A four-week trial.
• The treating practitioner concurrence when the LCMP performs the assessment/evaluation.

Noridian has created a Documentation Checklist for Pneumatic Compression Devices as a resource tool for suppliers and a guide for acquiring and maintaining good patient files.

Resources

• Local Coverage Determination (L33829)
• Policy Article (A52488)
• National Coverage Determination (280.6)
• Standard Documentation Requirements Policy Article (A55426)