Documentation - JD DME

Suppliers are reminded to review the Local Coverage Determination (LCD) and Policy Article for specific documentation guidelines.

Addendum - An addendum provides additional information that was not available at the time the services were rendered and the original entry. It does not delete or change any of the existing information in the medical record. Occasionally, certain entries related to services provided may not be properly documented. In this scenario, the documentation may need to be amended, corrected, or entered after the service has been rendered. The date and author of any amendment, correction or delayed entry should be identifiable, and the change/addenda should be clearly and permanently denoted. Reference CMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5

Beneficiary Authorization - A request for payment signed by the beneficiary must be on file or submitted with each claim.

Break in Need and Break in Billing - Break in need and break in billing are the most common denials when billing claims. This page identifies scenarios and how to identify which situation your break falls under and what is required for billing including claim narrative.

Master List - 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. The items on the required list, below, are selected from this master list.

Required Lists - Suppliers providing items on the Master List that also appear on the Required List must follow the requirements below.

• CMS Required Prior Authorization List
• Required Face-to-Face Encounter and Written Order Prior to Delivery List
• Face-to -Face (F2F) Encounter - Is a practitioner visit with a beneficiary within six (6) months preceding the order. The six-month timeframe requirement is only for items on the CMS F2F and WOPD Required List. A qualifying face-to-face encounter is required each time a new order/prescription for one of the specified items on the Required List is ordered.
• Written Order Prior to Delivery (WOPD) - Certain items require a completed SWO that is communicated to the DMEPOS supplier prior to the item's delivery. The WOPD must be on file with the supplier within six months of the F2F encounter. The WOPD follows the same documentation requirements as the Standard Written Order (SWO); the only difference is the timeliness requirement of the order (prior to delivery versus prior to claim submission). Applicable codes can be found on the Required List.

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).

Options for Submitting Documentation - Correspondence may be sent to Noridian via mail, fax, electronically by CD/DVD/USB, Electronic Submission of Medical Documentation (esMD), or the Noridian Medicare Portal (NMP).

Orders

• Standard Written Order (SWO) - Only type of order required for all dates of service on or after January 1, 2020. All policies require a SWO prior to billing, except for items on the Required Face-to-Face Encounter and Written Order Prior to Delivery (WOPD) List. These items require the order prior to dispensing an item.
  • All policies require a practitioner encounter confirming medical necessity for item(s) ordered. Follow individual policy guidelines.
• Written Order Prior to Delivery (WOPD) - Certain items require a completed SWO that is communicated to the DMEPOS supplier prior to the item's delivery. The WOPD must be on file with the supplier within six months of the F2F encounter. The WOPD follows the same documentation requirements as the Standard Written Order (SWO); the only difference is the timeliness requirement of the order (prior to delivery versus prior to claim submission). Applicable codes can be found on the Required List.
• Face-to-Face Encounter - Is a practitioner visit with a beneficiary within six (6) months preceding the order. The six-month timeframe requirement is only for items on the CMS F2F and WOPD Required List. A qualifying face-to-face encounter is required each time a new order/prescription for one of the specified items on the Required List is ordered.
• 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. Standard Documentation Requirements for all claims submitted to DME MACs reference.

Refill Documentation - Information regarding routine refills, itemized sales slips, documentation prior to delivery and other elements of refill records that pertain to all policies and was updated with a revision effective date of January 1, 2024. Individual LCDs may also have additional policy specific refill requirements. Refer to CMS Medicare Learning Network (MLN) Matters (MM) 13480 - Refillable DMEPOS Documentation Requirements for update.

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.

Telehealth - Services provided through telecommunications systems allow health care providers to give care to patients remotely in place of an in-person visit.