Prescription Must Be Supported by the Medical Record - Reminder

Recently, suppliers have asked questions about adding medical necessity to the prescription after the removal of the section that states "a prescription is not considered to be part of the medical record, except in the case of documenting medical necessity for replacement prosthetic limbs," from the Standard Documentation Requirements (SDR) for All Claims Submitted to DME MACs A55426 article.

Medical information intended to demonstrate compliance with coverage criteria may be included on a prescription but must be corroborated by information contained in the medical record. The CMS Internet Only Manual (IOM), Publication 100-08, Program Integrity Manual (PIM), Chapter 5, Section 5.9 states, "For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable)." If the prescription is the only place that medical necessity is listed, and corroborating medical records are not received for a review, the claim will be denied as not reasonable and necessary. For more information, review the SDR article for Orders and Documentation Requirements or the CMS IOM, Publication 100-08, Program Integrity Manual (PIM), Chapter 5, Section 5.9 Documentation in the Patient’s Medical Record.

Last Updated Dec 23 , 2024