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Documentation

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 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.

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 (required for dates of service on or after January 1, 2023 only).

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.

  • 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 17, 2023, this list includes 63 items. Items appearing on the Required List are subject to the face-to-face encounter and WOPD requirements.
  • 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).

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.

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 Thu, 02 Feb 2023 20:33:58 +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.

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