Article Detail - JA DME

Posted November 02, 2012

The Durable Medical Equipment Medicare Administrative Contractors have been conducting reviews on claims for consumable supplies. One of the top reasons for denials has been request for refill documentation. The most common errors involve how suppliers are documenting the quantity of an item the beneficiary has remaining.

For consumable supplies, i.e. those that are used up (e.g., ostomy, urological supplies, surgical dressings, or glucose supplies etc.) the supplier must sufficiently assess the quantity of each item that the beneficiary still has on hand, to determine that the amount remaining will be nearly exhausted. The following are some examples (not all-inclusive) of documentation that is not sufficient to justify reimbursement:

• "Yes" or "No" questions only regarding whether the beneficiary wants or needs more supplies.

• Documentation which only provides information regarding the amount of supplies the beneficiary is requesting.

• Documentation which only states that the beneficiary has less than the required threshold number of supplies left, e.g., Mrs. J stated that she has less than 14 days of glucose strips left.

Vague or nonspecific references to the quantity remaining are not sufficient to demonstrate compliance with the requirement that refills be provided when the current supply on hand is "approaching exhaustion". There must be an individualized and detailed record that quantifies the beneficiary's remaining supplies. An actual count is recommended but not necessary, but the record should evidence that an individual assessment has been performed. Note that a quantitative or semi-quantitative assessment actually performed individually for each refill would not have identical language in the record for each subsequent refill for the same beneficiary. Likewise, identical language for different beneficiaries would raise suspicions about whether individual assessments were actually performed.

There must be sufficient, specific and credible information regarding the quantity the beneficiary still has remaining for the reviewer to be able to determine that the quantity was actually assessed and will be approaching exhaustion on the delivery date, as required by CMS, Program Integrity Manual, Chapter 5, section 5.2.6.

For more information regarding these items and their requirements, refer to the local coverage determination and policy articles, Supplier Manual, and the standard documentation language articles.