Navigating DMEPOS Documentation Rules: Collect the Right Documentation Before Dispensing
By: Mary Ellen Conway, Capital Healthcare Group
Accounting for just 2% of the Centers for Medicare & Medicaid Services’ (CMS) overall spending1, durable medical equipment (DME) is a relatively tiny portion of the budget. But that doesn’t mean CMS isn’t trying to find ways to tighten spending and eliminate fraud.
To help achieve these goals, certain measures in the Affordable Care Act (ACA) mandated some new documentation requirements for durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) reimbursements that are effective now or are soon to be implemented.
Effective Now: Written orders prior to delivery
Suppliers used to be able to dispense most DMEPOS (except power-operated vehicles, power wheelchairs, and a few other items) with verbal orders or preliminary written orders. Now, however, CMS requires detailed written orders prior to delivery for all DME items. According to Medicare’s Program Integrity Manual (PIM), the written orders may be communicated in a variety of manners—electronic, paper or facsimile copies or “pen-and-ink” documents—but the contents must be detailed and specific and must include:2
- The start date of the order
- Details about the quantity of supplies required, frequency of change, and duration of need, when relevant
- All related details, including all options or additional features that will be billed separately or that will require an upgraded code
- Either a narrative description of the product needed or a brand name/model number
- Prescriber signature and date
To Be Implemented: Face-to-face encounters
In its current form, the rule requires that orders for DME be written after, but within six months of, a documented face-to-face encounter with a physician or eligible professional for a condition related to the DME need. In addition, the record regarding the encounter must specifically document the need for the DME items ordered.3
Multiple concerns with details of this mandate caused CMS to delay implementation for Medicare beneficiaries, but we’ve learned that it is scheduled to be implemented for Medicaid patients. However, it’s likely that some form will be implemented soon, so you should plan ahead and prepare. And if you already have a working system in place to address this requirement, continue to follow those procedures. See how CareTend’s HME document management system sends clean claims the first time!
The Nation’s Health Dollar; https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/NationalHealthExpendData/Downloads/PieChartSourcesExpenditures2014.pdf
Medicare Program Integrity Manual Chapter 5—Items and Services Having Special DME Review Considerations; http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/pim83c05.pdf
Face-to-Face Encounter Requirement for Certain Durable Medical Equipment; https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html.