Documentation - JA DME
Suppliers are reminded to review the Local Coverage Determination (LCD) and Policy Article for specific documentation guidelines.
Beneficiary Authorization - A request for payment signed by the beneficiary must be filed on or with each claim for charge basis reimbursement except in certain situations.
Break in Need or Service and Break in Billing - Break in Need or Service and Break in Billing are the most common situations for questions on what type of CMN/DIF/Order or what other information should be obtained/submitted on claims and what should be included in the narrative.
Certificates of Medical Necessity (CMNs) or DME Information Forms (DIFs) - A Certificate of Medical Necessity (CMN) or a DME Information Form (DIF) is a form required to help document the medical necessity and other coverage criteria for selected DMEPOS items. For certain items or services billed to a DME MAC, the supplier must receive a signed CMN from the treating practitioner or a signed DIF from the supplier.
CMS Durable Medical Equipment, Prosthetics, Orthotics, & Supplies (DMEPOS) Master List - CMS has streamlined regulatory requirements to help simplify DMEPOS payment requirements and reduce provider and supplier burden. The Master List serves as a library of Fee-for-Service DMEPOS codes that were flagged as potential vulnerabilities based on the criteria outlined in CMS-1713-F.
Providers and suppliers do not need to act unless an item on the Master List also appears on one or both Required Lists:
- Required Prior Authorization List
As of April 13, 2022, this list includes 62 items.
- Required Face-to-Face Encounter and Written Order Prior to Delivery List
As of April 13, 2022, this list includes 53 items.
The Required Lists Comparison Chart is a side-by-side crosswalk of both Required Lists.
Common Scenario Chart Requirement for Type of CMN/DIF/Order and Additional Information When Billing Claims - Chart provides the common scenarios with guidance on the type of CMN/DIF/Order those situations require and what type of narrative may be required when billing.
Continued Use/Continued Medical Need - As stated in the Standard Documentation Requirements Policy Article, continued use describes the ongoing utilization of supplies or a rental item by a beneficiary. Continued medical need requires information in the beneficiary's medical record to support that the item continues to remain reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review. Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.
Medical Records - The medical record is not limited to practitioner's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive).
- Standard Written Order (SWO) - Only one type of order needed for all dates of service on or after January 1, 2020. All policies require SWO prior to billing.
- Face-to-Face Encounter is an encounter with a beneficiary within six (6) months prior to prescribing item(s). All policies require face-to-face (F2F) encounter confirming medical necessity for item(s) ordered. Follow individual policy guidelines.
- Written Order Prior to Delivery (WOPD) is a completed SWO that is communicated to the DMEPOS supplier before delivery of the item(s). The WOPD must be on file with the supplier within six months of the F2F encounter unless the policy specifies a different timeline. The WOPD follows the same documented requirements as the Standard Written Order (SWO); the only difference is the timeliness requirements of the order, prior to dispensing versus prior to claim submission.
- Who can Order? Practitioners who can order DMEPOS
Pick Up Slips - A pick-up slip is written confirmation, provided by a supplier, that the supplier has removed an item of DME from the beneficiary's home.
Proof of Delivery - Proof of delivery ensures a supplier properly coded the item(s), that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are intended for, and received by, a specific Medicare beneficiary.
Refill Documentation - Information regarding routine refills, itemized sales slips, documentation prior to delivery and other elements of refill records is provided.
Requirement of New Orders - A new order is required when there is a change in the order for the item, if it is specified in the documentation section of a particular medical policy, when an item is replaced, and when there is a change of supplier.
Signature Requirements - For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand-written or an electronic signature. Stamp signatures are not acceptable.
Supplier Documentation - Suppliers are required to have documentation on file prior to submitting their claim to Medicare.
Last Updated Mon, 26 Sep 2022 18:29:56 +0000
The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.