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Simplifying Documentation Requirements

Medicare is simplifying documentation requirements so that you spend less time on paperwork, allowing you to focus more on your patients and less on confusing and time-consuming claims documentation. We've made some important changes already. We need your suggestions on where to focus next. Please send your feedback and suggestions to ReducingProviderBurden@cms.hhs.gov.

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:

Simplify remaining sub-regulatory documentation requirements and Eliminate sub-regulatory documentation requirements that are no longer needed.

Recent Updates

1. 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.

CMS uses change request documents to update and make clarifications for MACs. View the change request for DME POD requirements, here.

2. 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.

View the change request for this clarification, here.

3. 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.

Read this Medicare Learning Network article to learn more.

4. 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.

Read more about the clarification in this Medicare Learning Network article.

5.  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.

 Read more about the change in this Medicare Learning Network article. 

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.

Learn more.

Read about all the ways the Center for Program Integrity is reducing provider burden, including simplifying medical reviews with the Targeted Probe and Educate program.

CMS is putting Patients Over Paperwork. Read more on the Patients Over Paperwork webpage.

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