Article Detail - JA DME

Dear Physician:

The Comprehensive Error Rate Testing (CERT) Contractor, under contract with the Centers for Medicare & Medicaid Services (CMS), performs medical review audits for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) provided to Medicare beneficiaries to determine the paid claims error rate for Medicare contractors and providers.

The CERT Contractor may request that your patient's supplier obtain information from you in order to verify that Medicare coverage criteria have been met in dispensing the item(s) ordered by you. The supplier must submit the documentation to CERT within 30 days from the date of his/her receipt of the initial request letter. Failure to respond to the CERT's request for documentation will result in an error and recoupment of the paid claim.

Medicare covers Enteral Nutrition under the Prosthetic Device Benefit as established by the Social Security Act §1862 (a)(8). Please refer to the Local Coverage Determination (LCD) on Enteral Nutrition, the related Policy Article and the Supplier Manual for additional information about coverage, billing and documentation requirements. You may access the Enteral Nutrition LCD on the CMS web site under the Medicare Coverage Database.

Your patient's medical record must contain sufficient information about his/her medical condition to substantiate that the applicable Medicare coverage criteria have been met. This information must justify the type of enteral nutrient ordered by you, how it is administered and the frequency of feedings. Also, as for all orders written by you for DMEPOS items for your Medicare patients, you are responsible for completing a detailed written order for each item. The detailed order requirements are also listed within the Enteral Nutrition LCD.

The most common CERT error related to clinical record documentation for Enteral Nutrition is the failure to show that the patient initially met the coverage criteria. Another frequent CERT error is the failure to establish the medical need for the patient to stay on Enteral Nutrition ("continued medical need"). To validate this, the supplier may use the physician's clinical record showing that the physician made an indication of this within the preceding 12 months of the date of service being reviewed.

DMEPOS suppliers are your partners in caring for your patient. They will not receive payment from Medicare for the items that are ordered for your patient if you do not provide information from your medical record when it is requested. Furthermore, if you do not provide this information to the supplier for this audit, your patient may have to pay for the item. Finally, your cooperation is a legal requirement as outlined in the Social Security Act which is the law governing Medicare.

Please do not send medical records that your supplier requests from you directly to the DME MAC, but rather return them to him or her. Also, please remember that you may not charge the supplier or the beneficiary to provide this information. Help your DMEPOS supplier continue to provide the highest quality of service to your patient by promptly providing the information from your medical record that is requested.

Sincerely,

Paul J Hughes, M.D.

Medical Director, DME MAC, Jurisdiction A

NHIC, Corp.

Stacey V. Brennan, M.D., FAAFP

Medical Director, DME MAC, Jurisdiction B

National Government Services

Robert D. Hoover, Jr., MD, MPH, FACP

Medical Director, DME MAC, Jurisdiction C

CGS Administrators, LLC

Eileen M Moynihan, MD, FACP, FACR

Medical Director, DME MAC, Jurisdiction D

Noridian Healthcare Solutions