Simplifying Documentation Requirements
To make it easier for providers and reduce improper payments and appeals, CMS is implementing the Documentation Requirements Simplification (DRS) Initiative. The key objectives of this initiative are:
- Clarified acceptable documentation for diagnostic laboratory tests.
BEFORE: Our instructions were silent about how much information was required in the medical record to show a physician’s intent to order lab tests.
AFTER: A signed order, a signed requisition or a signed medical record that supports the physician/practitioner’s intent to order tests (e.g. “order labs, “check blood”, “repeat urine”) can satisfy the order requirements for labs.
- Provided an exception so that physicians acting as suppliers do not need to write orders to themselves.
BEFORE: The manual did not provide an exception to the written order requirements for physicians that provide DMEPOS to their own patients (in accordance with self-referral laws).
AFTER: A physician acting as a supplier does not need to write him/herself an order. We will consider any medical documentation (e.g., progress note) with all necessary information as meeting the requirements for an order.
- Eliminated the requirement that physicians indicate where in the medical record certification/recertification elements can be found.
BEFORE: Information contained in other provider records, such as physicians’ progress notes, need not be repeated in the certification or recertification statement itself. However, regulation required physicians to note page numbers where that information could be found.
AFTER: Physicians do not need to reference page numbers in their certification or recertification statements.
- Explained that a signature and date is acceptable verification of a medical student’s documentation of an E&M visit performed by a physician
BEFORE: As of January 1, 2018 a teaching physician does not have to re-document a medical student’s notes of an E&M visit, but can verify them. Our instructions didn’t specify what acceptable verification is for medical review purposes.
AFTER: If a teaching physician chooses to rely on the medical student documentation and chooses not to re-document the E&M service, contractors will consider this requirement met if the teaching physician signs and dates the medical student’s entry in the medical record.
- Simplified the requirements for preliminary/verbal DMEPOS orders.
BEFORE: Our instructions were not clear about whether preliminary (verbal) orders for DMEPOS items were conditions of payment.
AFTER: Suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician. However, Medicare medical review contractors will look to the signed, written order to see if the item meets our payment requirements.
- Clarified DMEPOS written order prior to delivery date requirements.
BEFORE: There was confusion about whether contractors needed to verify that a written order was received by checking for a fax transmittal date or a date stamp.
AFTER: If the written order is dated the day of or prior to delivery there’s no need for affirmative documentation of its being “received”.
- Clarified proof of delivery (POD) requirements
BEFORE: The Durable Medical Equipment (DME) Medicare Administrative Contractors (MACs) help CMS oversee the DME benefit. Some DME MACs were routinely auditing suppliers for proof of delivery for every claim they reviewed. Suppliers maintain proof of delivery but often fail to meet a technical requirement necessary for compliance.
AFTER: New guidance advises MACs to request proof of delivery documentation for DME items only if it is required as a condition of payment, for example, as a written order prior to delivery for Power Mobility Devices. The guidance also simplifies CMS documentation instructions. While suppliers are still required to keep proof of delivery for every item they bill, and may be requested to provide such documentation to other review entities, this should reduce the amount of paperwork suppliers are required to submit to MACs during medical review.
- Clarified signature requirements
BEFORE: CMS contractors denied claims when a nurse initialed a medication administration log instead of including a full signature.
AFTER: We've clarified guidance to explain that providers ultimately responsible for the beneficiary's care must sign the medical record. Claims won't be denied if a support care provider, such as a nurse documenting chemotherapy, doesn't sign part of the record.
- Clarified medical review of inpatient rehabilitation facility (IRF) claims
BEFORE: IRF claims were denied even though patients needed and could benefit from an inpatient rehabilitation program.
AFTER: CMS clarified guidance to its contractors, requiring them to use clinical review judgment to determine medical necessity of the intensive rehabilitation therapy program based on the individual facts and circumstances of the case, and not based on any threshold of therapy time.
- Clarified billing for Immunosuppressive Drugs
BEFORE: If a supplier mailed an immunosuppressive drug shortly before the end of a beneficiary’s inpatient stay and used the mailing date as the date of service, the claim could be rejected. This happened because the claim’s date of service preceded the beneficiary’s date of discharge.
AFTER: We clarified that a supplier can use the discharge date as the date of service if mailing one or two days before discharge.
- Allowed teaching physicians to verify student’s Evaluation and Management visit notes
BEFORE: Teaching physicians had to re-document most updates even when they concurred with what the medical student wrote in the patient’s medical record.
AFTER: We revised the manual instructions to allow teaching physicians to verify in the medical record any student documentation of billable services, rather than re-documenting the work.
We want your ideas!
Please email us at ReducingProviderBurden@cms.hhs.gov and tell us which requirements you find difficult to follow or understand.
We want to make documentation simpler for everyone.