New Dear Physician Letter Released, Providers Be Warned

Posted on in Billing/Reimbursement

The DME MACs released two new Dear Physician letters in January 2016, for PAP equipment and items provided on a recurring basis and request for refills. Usually when this happens, it means they (the reviewers) are looking for certain information when performing a review/audit. When I see these types of letters released, it tells me that this is our warning. The same thing happened with oxygen equipment. A new Dear Physician letter was released in July 2015, that discussed alternative treatments being tried/considered and ruled out. Shortly after, suppliers started receiving denials because there was nothing in the notes about alternative treatments.

What is in these letters that may be on the target for reviews/audits?

PAP Device

The letter mentions signs and symptoms in the face-to-face evaluation that needs to occur prior to the sleep study. Now, this same information has been in the PAP policy for several years, but Medicare has not really looked for this information during audits. Their concern has been with making sure a face-to-face has occurred prior to the sleep study.

The letter and policy PDF states:

For the initial evaluation, the report would commonly document pertinent information such as signs and symptoms of sleep-disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headaches; the duration of those symptoms and a validated sleep hygiene inventory but may include other details as well.

Also a pertinent physical examination assessing e.g., body mass index, neck circumference, upper airway exam and cardiopulmonary exam. It is not necessary for all of the above to be present; however, it is critical that there be detailed information that identifies symptoms commonly associated with obstructive sleep apnea.

Make sure you are sharing this letter with your referral sources. More specifically, those referrals that determine when a patient needs to have a sleep study, such as family practitioners, primary care physicians, pulmonologists, etc.

Items Provided on a Recurring Basis and Request for Refill Requirements

The letter stresses that the suppliers must have contact with the patient or caregiver prior to dispensing a new supply of items. If the patient comes into the store for the supplies, make sure it’s clear on the delivery ticket that the supplies were picked up in the store. This can be done either by changing the delivery address to the store address or writing on the delivery ticket the suppliers were picked up in the store.

For those items actually delivered to the patient, make sure to follow the refill requirements by getting the necessary information documented. See the letter for more information.

This letter also discusses the quantities dispensed to a patient:

Suppliers must not dispense a quantity of supplies exceeding a beneficiary's expected utilization. Suppliers must stay attuned to changed or atypical utilization patterns on the part of their clients. Suppliers must verify with the ordering physicians that any changed or atypical utilization is warranted. Regardless of utilization, a supplier must not dispense more than a one- or three-month quantity at a time.

The letter concludes by stating these requirements are not limited to DMEPOS refill items as mentioned in LCDs only. ALL DMEPOS items that are refilled on a recurring basis are subject to these requirements.

When in doubt, get a new order for any refill such as CPAP supplies, oxygen content, surgical dressings, nutrition supplies, diabetic test strips, etc. Another example, watch capped rental items. If the order indicates a length of need for 12 months, then it’s only good for 12 months. A refill order would be needed for the 13th month. 

Remember that it’s important for your business to get paid for the services that are provided. Read these new Dear Physician letters, make sure to share with your staff, and more importantly, educate your referrals sources: physicians, hospitals and anyone involved in the patient’s care.

If you have questions, please contact me.

Ronda Buhrmester, CRT
[email protected]