Go Extra Mile in Cognizance for Documentation Requirement to Escape DME Declination
Durable Medical Equipment billing has always remained under the scanner of Medicare and auxiliary commercial carriers. Conventionally, the Centers of Medicare and Medicaid Services (CMS) endeavors comprehensive and precise documentation guidelines for DME as well as other regulations for documentation that can be endowed in Local Coverage Determination (LCDs) and National Coverage Determination (NCDs). Everyone, be it Podiatrists, orthopedic surgeons, physical and occupational therapists, orthotics and orthotic technicians, administrators and office managers, coders, billers, transcription, and scribes needs to understand DME documentation requirements. Without understanding and rigorously following documentation requirements, you are putting the whole organization at risk at times of inspection and audit.
The scenario can lead to the worst conditions where refunding of insurance carriers or CMS can be made which will be a damaging situation for the organization concerning revenue and reputation. Complicated documentation requirement for general, as well as specific rules for DME requirement, is essential to get in the habit. Errors reported in Medicare audits are mainly due to claims submitted with incomplete or misplaced requisite documentation. Accordingly, the Durable Medical Equipment Medicare Administrative Contracts (DME MACs) have formed a homogenized terminology for facilitating Durable Medical Equipment, Prosthetics, Orthotics and supplies (DMEPOS) to justify conditions to make payment.
The tedious documentation process for DMEs includes paper trail that massively supports the medical necessity of the DME. For DME supplies that require prior approval, a provider prescription and clinical documentation are necessary and must support this requirement. Medicare requires an appropriate prescription before approving payment for any DME. This prescription may commence with a physical therapist affirming the documentation process. The supporting script and documentation need to prove medical necessity, which requires the following information:
- Patient's medical record
- Licensed provider plan of treatment
- Apprehended benefits and outcomes of DME’s usage
- Comprehensive member’s clinical and functional status to determine medical necessity
Evading inadequate documentation errors:
In a case where your medical payment is needed to be done, including just one physician's signature will put your claim under the category of insufficient documentation error. If the reviewer doesn't find the allowed services necessary or allowed without proper documentation, then the chances are high that your claim falls under documentation error. The Medicare's learning network "Complying with medical record documentation requirements” configures insufficient document errors; so here's how to avoid it:
- According to MLN Matters Article MM8304, check with DME Healthcare Common Procedure Coding System (HCPCS) codes like glucose monitor, manual wheelchairs, etc. require a valid detail written order before delivery.
- Make sure to know that the ordering physician and DME supplier is actively enrolled in Medicare on the service date because only on being actively enrolled and involved, Medicare will approve your claim.
- Also make sure to fulfill that the physician, Physician's Assistant, Nurse Practitioners, and Certified Nurse Specialist interact face- to- face with the beneficiary at least six months before ordering from the DME supplier.
Use appropriate modifiers to check the proper documentation to avoid reimbursement denials. Understand the latest policies or alteration in the current plans to prevent any contradictions or errors.
On the futuristic note:
The latest verdict by the U.S. Supreme Court, united with the OIG’s recent recommendations and CMS’ new “pricey” DME review program, highlights suppliers the relevance of security and retention medically essential documents.
The U.S. Supreme Court denied review in the Maximum comfort case resolving the legal debate about whether a CMN may be a sole basis for claiming Medicare coverage and high DME payments.In addition to this, three courts of appeals have affirmed the principle of supporting medical documentation with CMN may be required to establish Medicare coverage.