Detailed Written Orders
A DWO is required before billing. Someone other than the physician/practitioner may complete the DWO of the item unless statute, manual instructions, the contractor's LCD or policy articles specify otherwise. However, the prescribing physician/practitioner must review the content and sign and date the document. It must contain:
- Beneficiary's name
- Date of the order
- A description of all items, options, accessories or additional features that are separately billed or require an upgraded code. The description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number.
- For supplies - list all supplies that are separately billable, and for each include the frequency of use (if applicable), and the quantity dispensed
- Prescribing physician/practitioner's signature (and date if applicable - see above)
For drugs used as a supply for a DME item, the written order must include:
- Beneficiary name
- The name of the drug
- Dosage or concentration (if applicable)
- Frequency of administration (if applicable)
- Duration of infusion (if applicable)
- Quantity to be dispensed
- Number of refills
- Date of the order
- Physician/practitioner's signature
For the "Date of the order" described above, use the dispensing order date i.e., the date the supplier was contacted by the prescribing physician/practitioner (for verbal orders) or the date entered by the prescribing physician/practitioner (for written dispensing orders).
Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state "PRN" or "as needed" utilization estimates for replacement frequency, use, or consumption are not sufficient to justify payment.
An exception to the requirement for a detailed written order applies in those limited instances in which the prescribing practitioner is also the supplier and is permitted to furnish specific items of DMEPOS and fulfill the role of the supplier in accordance with any applicable laws and policies. In such cases, a separate order is not required, but the medical record must still contain all of the required order elements.
Signature and date stamps are not allowed. Signatures must comply with the CMS signature requirements outlined in PIM 22.214.171.124.
The DWO must be available upon request.
A prescription is not considered as part of the medical record. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.
If a supplier does not have a faxed, photocopied, electronic or pen and ink detailed written order signed and dated by the treating physician/practitioner in their records before they submit a claim to Medicare (i.e., if there is no order or only a verbal order), the claim will be denied. If the claim is for an item for which an order is required by statute (e.g., therapeutic shoes for diabetics, oral anticancer drugs, oral antiemetic drugs which are a replacement for intravenous antiemetic drugs), the claim will be denied as not meeting the benefit category and is therefore not appealable by the supplier (see CMS Manual System, Pub. 100-04, Medicare Claims Processing Manual, Chapter 29, for more information on appeals). For all other items, if the supplier does not have an order that has been both signed and dated by the treating physician before billing the Medicare program, the item will be denied as not reasonable and necessary, with the exception of items requiring a written order prior to delivery as indicated below.
If an order is taken verbally and sent to the physician for a signature and date, there are two documents: the verbal order and the written order with the physician's signature and date.
If a beneficiary comes in with a prescription containing all of the elements of a detailed written order, then one document is on file.
It is important to remember that if an item is dispensed based on a verbal order and a written order is provided afterwards, both orders must be retained. It is not adequate to only have a written order after dispensing an item. There must be documentation to show the verbal order was received prior to dispensing the item.
Example: The treating physician calls the supplier and prescribes a glucose monitor with a verbal order. The supplier can then create a detailed written order that includes an itemized listing of all directly related, separately billable items - i.e., the glucose monitor, test strips, lancets, calibration solution, batteries and lancing device. This detailed written order is then returned to the physician for their signature.
Although the initial dispensing order from the physician did not specifically include the test strips, lancets, and other supplies, they are clearly related to the glucose monitor. Therefore, it is an acceptable detailed written order. For detailed written orders of this type, no further action is required from the physician beyond their signature and date. However, for other types of detailed written orders other actions by the physician may be required. (See below)
In the example above, it is not acceptable for the supplier to include additional, unprescribed and unrelated items, such as a vacuum erection device, water circulating heating pad or wrist orthosis to the detailed written order. While the test strips, lancets, and other supplies are related to the glucose monitor in the original order, the vacuum erection device, water circulating heating pad and wrist orthosis are not related and therefore must not be included on the detailed written order.
Some suppliers use preprinted forms for their detailed written orders that include a listing of many different items, not all of which may be needed by an individual beneficiary. These listings often create incompatible combinations. For example, an order form for CPAP accessories might list all possible interfaces. On these forms, the final document that is signed and dated by the physician must clearly identify the specific items that are being ordered for that patient. This may be accomplished in one of two ways:
- The supplier may indicate the items that are being provided before sending the form to the physician. The physician can then review the form and accept either the items marked by the supplier or make any necessary changes. The physician must then initial and date the revised entries; or
- The supplier may send the form to the physician without any items selected and ask the physician to indicate which items are being ordered. The physician must make their choice clear. Check marks, circling items or other affirmative indicators are acceptable ways to show that the physician selected the item(s).
In each case, the physician must sign and date the form.
The following are examples (not all-inclusive) of forms listing multiple items, which would be considered invalid detailed written orders:
- Forms listing incompatible items without specific items being selected. For example, for CPAP, a form which includes full-face mask, nasal mask, and nasal pillows with none being specifically selected by the physician.
- Forms in which incompatible items are checked off or selected by either the supplier or the physician. For example, a form which includes full-face mask, nasal mask, and nasal pillows and two or all three are selected.
- CMS Internet Only Manual (IOM) Publication 100-08, Medicare Program Integrity Manual (PIM), Chapter 5, Section 5.2.3
Last Updated Apr 18, 2019