By: Kelly Grahovac, The van Halem Group
In the month of February I traveled to four different cities for various association meetings, conferences or on-site client visits. During my travels I encountered suppliers that are all have or are currently being audited by one of many CMS contractors. Some suppliers indicated that the DME MACs’ prepayment review letters (ADRs) come to their office on a weekly basis. Others are experiencing postpay reviews from the ZPIC. These audits are considerably daunting and, when not handled appropriately, could result in 100% prepayment review of your claims or even revocation of your supplier number.
No matter the type of audit, one thing is certain. Preparing your files to be audited is your best defense. Although you, the supplier, has control over your own records, the documentation that is provided by the physician is heavily scrutinized by auditors to ensure medical necessity and coverage by Medicare is justified. Below I have provided answers to the common questions you encounter when requesting medical records from the beneficiary’s physician. Within the answers you will also see references from the IOM, Social Security Act and the Code of Federal Regulations for you to use when educating your physicians on the importance of their role in the documentation process.
Why do you need me to document?
For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable)…neither a physician’s order nor a CMN…nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN…or information on a supplier prepared statement or physician attestation (if applicable). [PIM Chapter 5, Section 5.7]
Title XVIII Section 1842(p)(4): In the case of an item or service defined in paragraph (3), (6), (8), or (9) of subsection 1861(s) ordered by a physician or a practitioner specified in subsection (b)(18)(C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.
What are the consequences to me if I don’t?
42 Code of Federal Regulations (CFR) § 424.535:
A referring/ordering physician’s failure to provide the above required documentation may result in the revocation of enrollment and billing privileges in the Medicare program:
- Reasons for revocation. CMS may revoke a currently enrolled provider or supplier's Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons:
The other guys don’t make me do this, why are you?
- Failure to document or provide CMS access to documentation. (i) The provider or supplier (as described in section 1866(j) of the Act) did not comply with the documentation or CMS access requirements specified in §424.516(f) of this subpart.
It is ours, and your, legal obligation to comply with Medicare rules and regulations. In an environment of strict regulatory oversight we work hard to be compliant in our business practices. The other suppliers that are not collecting documentation from you may not be in compliance.
On March 15, 2013, Chapter 3, Section 126.96.36.199.1(C)
of the Program Integrity Manual was amended to state that “physicians/LCMPs [licensed/certified medical professionals] who fail to submit documentation upon a supplier’s request may trigger increased MAC or RAC review of the physician/LCMP’s evaluation and management services”.
Can you make it easier on me?
CMS also amended Chapter 3, Section 188.8.131.52.1(B)
, probably in an effort to prepare for the use of eMR. The amended section states “CMS does not prohibit the use of templates to facilitate record-keeping.”
The PIM goes on to define a template as a “tool/instrument that assists in documenting a progress note.”
Based on the above, a physician may use a template or form when documenting the need for the durable medical equipment. To be clear, templates cannot merely contain check boxes, predefined answers, or have limited space to enter information. These types of templates often fail to capture sufficient detailed clinical information to demonstrate that all coverage and coding requirements are met. There must be sufficient space for free form information specific to the patient. A supplier generated form is not considered to be part of the medical record and is only used to gather information. However, a physician may create a form that is used when ordering prosthetics/orthotics. Physicians who use templates must make them the default method of documentation for prosthetics/orthotics. This means that the form must be completed for use on all patients in which the physician prescribes prosthetics/orthotics, not just when prescribing for one supplier.
What does my documentation need me to say?
Many of the prosthetics/orthotics that you prescribe have local coverage determinations (LCDs) that contain the criteria for coverage. The criteria listed in the Coverage Indications, Limitations, and/or Medical Necessity section of the LCD is what must be supported in your notes. You can access the LCDs from the respective DME MAC Jurisdiction’s website.
The bottom line is that if you are waiting for the audit letter to arrive, you are already too late and may not avoid paying money back to Medicare. Obtaining the appropriate documentation prior to billing, or as quickly as possible, is your only defense. Neither the DME MAC, nor the Part B MAC, is contracted to educate physicians on DMEPOS documentation requirements. This means that the burden to educate physicians on the documentation you need for your patients to meet Medicare guidelines is on you - the supplier. Work with your referral sources to understand the significance of their documentation in relation to the equipment they refer for you to provide and convey to them their role in the audit process.