MLN4824456 – Medicare Provider Compliance Tips

DMEPOS General Documentation Requirements

Documentation requirements apply to certain DMEPOS items.

All claims billed to Medicare require a written order or prescription from the treating practitioner as a condition for payment, which must meet standard written order (SWO) requirements.

To justify payment, suppliers must meet these requirements:

SWO
Medical record information (including continued need and use if applicable)
Correct coding
Proof of delivery (POD)

NOTE:

Section 5.10 of the Medicare Program Integrity Manual, Chapter 5 states that suppliers must keep POD in their files for 7 years, starting from the date of service, and must provide documents to their DME Medicare Administrative Contractor (MAC) upon request.

The treating practitioner must communicate an SWO to the supplier before submitting a claim. For certain DMEPOS items, we require a written order prior to delivery before delivering the items to the patient.

An SWO must have:

The patient’s name or MBI
The order date
A general item description:
- This can be a general description (for example, wheelchair or hospital bed), an HCPCS code, an HCPCS code narrative, or a brand name or model number
  - For equipment: Besides description of a base item, the SWO may include all concurrently ordered options, accessories, or other features that are separately billed or require an upgraded code (list each separately)
  - For supplies: Besides description of a base item, the SWO may include all concurrently ordered supplies that are separately billed (list each separately)
The dispensed quantity, if applicable
- Prescriptions may be refillable
The treating practitioner’s name or NPI and signature

Signature and date stamps aren’t allowed, with a few exceptions. You must follow the signature requirements in Section 3.3.2.4 of the Medicare Program Integrity Manual, Chapter 3.

The Complying with Medical Record Documentation Requirements and Complying with Medicare Signature Requirements fact sheets have more guidance.

NOTE:

Article: Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426) has more information about these requirements.

Lab Test Order Requirements

You, the physician, practitioner, or NPP who’s treating the patient (and who provides a consultation or treats them for a specific medical problem and uses the results to manage their specific medical problem) must order the tests. Tests you haven’t ordered for treating the patient aren’t reasonable and necessary.

Document medical necessity in the patient’s medical record when ordering the service.

The entity submitting the claim must keep documentation from you, which includes:

Documentation of the order for the service billed (including information that allows us to find and contact the ordering provider)
Documentation showing correct order processing and claim submission
Diagnostic or other medical information you provided to the lab (including any ICD-10-CM code or narrative description)

Diagnostic lab test orders require 1 of these:

A signed order or signed requisition listing the specific test
An unsigned order or unsigned lab requisition listing specific tests done
An authenticated medical record that supports your intent to order specific tests

NOTE:

Section 6.9.1 of the Medicare Program Integrity Manual, Chapter 6 has more information on order requirements.

You can deliver an order through:

Written and signed document that’s hand delivered, mailed, or faxed to the testing facility. We don’t need your signature on orders for clinical diagnostic tests paid based on the clinical lab fee schedule, physician fee schedule, or for physician pathology services.
Call from you or your office to the testing facility.
Email from you or your office to the testing facility.

Section 80.6 of the Medicare Benefit Policy Manual, Chapter 15 has more information.

NOTE:

If you communicate the order by phone, you or your office staff and the testing facility must document the call in the respective patient’s medical record. We don’t require a signed order, but you must clearly document in the medical record your intent to do the test.

The Complying with Medical Record Documentation Requirements and Complying with Medicare Signature Requirements fact sheets provide more guidance.

Medical record documentation should include enough information to show the ordered or provided tests are reasonable and necessary, per 42 CFR 410.32.

Signature and date stamps aren’t allowed, with a few exceptions.

“Other” Errors

“Other” errors include duplicate payment, non-covered or unallowable service, or ineligible Medicare patient errors.

Disclaimers

CPT codes, descriptions, and other data only are copyright 2022 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply. Fee schedules, relative value units, conversion factors and/or related components are not assigned by the AMA, are not part of CPT, and the AMA is not recommending their use. The AMA does not directly or indirectly practice medicine or dispense medical services. The AMA assumes no liability for data contained or not contained herein.

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