Please do not use this feature to contact CMS. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. accuracy of any information contained in this material, nor was the AHA or any of its affiliates, involved in the CPT is provided "as is" without warranty of any kind, either expressed or implied, including but not limited to, the implied warranties of merchantability and fitness for a particular purpose. In such instances, if statutory requirements related to the order are not met, the claim will be denied as not meeting the benefit category. Please contact the Medicare Administrative Contractor (MAC) who owns the document. THE UNITED STATES Verify that a qualifying face-to-face encounter occurred within the 6-months prior to the date of their prescription; and. The condition of the device, or the part of the device, requires repairs and the cost of such repairs would be more than 60 percent of the cost of a replacement device, or, as the case may be, of the part being replaced. This Agreement will terminate upon notice if you violate its terms. If you have questions, please contact the PDAC HCPCS Helpline at (877) 735-1326 during the hours of 9:30 a.m. to 5:00 p.m. Response to Comment (RTC) articles list issues raised by external stakeholders during the Proposed LCD comment period. Current Dental Terminology © 2022 American Dental Association. Revision Effective Date: 01/01/2019DOCUMENTATION REQUIREMENTS:Added: Narrative section to clarify longstanding claims processing instructionsAdded: Date Span section to clarify longstanding claims processing instructions. . Revision Effective Date: 01/01/2020 PRESCRIPTION (ORDER) REQUIREMENTS: Revised: Title to ORDERS Revised: Language based on Final Rule 1713-F NEW ORDER REQUIREMENTS: Revised: Language based on Final Rule 1713-F DISPENSING ORDERS: Deleted: Entire section based on Final Rule 1713-F DETAILED WRITTEN ORDER: Revised: Title to STANDARD WRITTEN ORDER (SWO) based on Final Rule 1713-F Revised: Language based on Final Rule 1713-F WRITTEN ORDERS PRIOR TO DELIVERY (WOPD): Revised: Language based on Final Rule 1713-F POWER MOBILITY DEVICES WOPD (7 ELEMENT ORDER):Deleted: Entire section based on Final Rule 1713-FPOWER MOBILITY DEVICES DETAILED PRODUCT DESCRIPTION: Deleted: Entire section based on Final Rule 1713-F WOPD FOR SPECIFIED DMEPOS ITEMS (5 ELEMENT ORDER): Deleted: Entire section based on Final Rule 1713-FDOCUMENTATION REQUIREMENTS: Revised: Language based on Final Rule 1713-F FACE-TO-FACE EXAMINATION FOR SPECIFIED DMEPOS ITEMS: Revised: Title to FACE-TO-FACE ENCOUNTERRevised: Language based on Final Rule 1713-FFACE-TO-FACE REQUIREMENTS:Deleted: Title of section CERTIFICATE OF MEDICAL NECESSITY (CMN) & DME INFORMATION FORM (DIF): Revised: Language based on Final Rule 1713-F. 01/02/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. In the event of a claim review, information contained directly in the contemporaneous medical record is the source required to justify payment except as noted elsewhere for prescriptions and CMNs (for DOS prior to 01/01/2023). The definition of replacement is found in the Medicare Benefit Policy Manual (CMS Pub. Articles often contain coding or other guidelines that are related to a Local Coverage Determination (LCD). The contractor information can be found at the top of the document in the Contractor Information section (expand the section to see the details). For more information: CR 11104 (PDF) (Implementation date April 22, 2019). The medical record chronologically documents the care of the patient and is an important element contributing to high-quality care. For dates of service for which a DIF is required, a DIF, which has been completed, signed, and dated by the supplier, must be kept on file and made available upon request. Local Coverage Articles are a type of educational document published by the Medicare Administrative Contractors (MACs). lock The documentation requirements are compiled from Statutes, Code of Federal Regulations, Centers for Medicare and Medicaid Services (CMS) National Coverage Determinations (NCDs), CMS rulings and sub-regulatory guidance (CMS manuals), and DME MAC publications. Signature and date stamps are not allowed. Any of the following may serve as documentation justifying continued medical need: Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy. A WOPD must be completed within six (6) months after the required face-to-face encounter. Under CERT, we review a random sample of all Medicare FFS claims to determine if we paid them properly under Medicare coverage, coding, and billing rules. Contractors may specify Bill Types to help providers identify those Bill Types typically PDF Medicare's Wheelchair & Scooter Benefit CMS is putting Patients Over Paperwork. This revision is to an article that is not a local coverage determination. Reimbursement shall be based on the specific utilization amount that is supported by contemporaneous medical records. For the purposes of reasonable useful lifetime and calculation of continuous use, the first day of the first rental month in which Medicare payments are made for the item (i.e., DOS) serves as the start date of the reasonable useful lifetime and period of continuous use. For certain items or services billed to a DME MAC, the supplier must receive a signed CMN from the treating practitioner. The CMN may act as a substitute for a SWO if it contains all the required elements. Pursuant to Final Rule 1713 (84 Fed. Applications are available at the AMA Web site, http://www.ama-assn.org/go/cpt. Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary: Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in this policy. authorized with an express license from the American Hospital Association. Heres how you know. All Policy Specific Documentation Requirements are located in the LCD-related Policy Article, which is linked to the applicable LCD. The AMA assumes no liability for data contained or not contained herein. For items that the beneficiary obtains in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill. If the item has been in continuous use by the beneficiary on either rental or purchase basis for its RUL, the beneficiary may elect to obtain a replacement. There are three methods of delivery. Prescribing of DMEPOS is limited by Medicare regulations and by the treating practitioners respective scope of practice as determined by the state wherein they practice. Does the Plan of Care contain: All pertinent diagnoses Patient's mental, psychosocial, and cognitive status Types of services, supplies, and equipment required Frequency and duration of visits to be made Prognosis Rehabilitation potential Functional limitations Activities permitted Nutritional requirements All medic. A POD is required for all items, even those in the beneficiary's possession provided by another insurer prior to Medicare eligibility. For Medicare to provide payment, the beneficiary must meet all Medicare coverage, coding, and documentation requirements for the DMEPOS items in effect on the DOS of the initial Medicare claim. Note: The information in this document supersedes the material currently contained in all LCDs and related policy articles. Under this program, your CMS DISCLAIMS RESPONSIBILITY FOR ANY LIABILITY ATTRIBUTABLE TO END USER USE OF THE CPT. Medicare does not separately reimburse for repairs of: A new CMN and/or treating practitioners order is not needed for repairs. Additional DMEPOS items selected by CMS appearing on the Required List. For the purpose of the delivery methods noted below, designee is defined as any person who can sign and accept the delivery of DMEPOS on behalf of the beneficiary. The supplier must have a signed and dated DIF in their records when submitting a claim for payment to Medicare. You can use the Contents side panel to help navigate the various sections. A POD is required for all items, even those in the beneficiarys possession provided by another insurer prior to Medicare eligibility. the supplier must assess the quantity of each item that the beneficiary still has remaining to document that the amount remaining will be nearly exhausted on or about the supply anniversary date. The face-to-face encounter must support payment for the item(s) ordered/prescribed, and be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). To register, simply click here ! Replacement of items due to irreparable wear takes into consideration the Reasonable Useful Lifetime (RUL) of the item. Billing and Coding articles provide guidance for the related Local Coverage Determination (LCD) and assist providers in submitting correct claims for payment. If that doesnt work please contact, Technical issues include things such as a link is broken, a report fails to run, a page is not displaying correctly, a search is taking an unexpectedly long time to complete. In order for a claim for Medicare benefits to be valid, there must be sufficient documentation in the provider's or hospital's records to verify the services performed were "reasonable and necessary" and required the level of care billed. Items appearing on the Required List are subject to the face-to-face encounter and WOPD requirements. This type of POD document must contain the information specified above. CONTINUOUS GLUCOSE MONITORS - Noridian Medicare Medicare does not automatically continue coverage for any item obtained from another payer when a beneficiary transitions to Medicare coverage. In order for CMS to change billing and claims processing systems to accommodate the coverage conditions within the NCD, we instruct contractors and system maintainers to modify the claims processing systems at the national or local level through CR Transmittals. Documentation Requirements The following list may be used as reference guides, when submitting documentation to Medicare. 7500 Security Boulevard, Baltimore, MD 21244. Review the article, in particular the Coding Information section. The supplier should also obtain as much documentation from the patient's medical record in order to assure themselves that coverage criteria for an item have been met. You may also visit the PDAC website to chat with a representative or select the Contact Us button at the top of the page for email inquiry, FAX or postal mail information. CMS requires that in the event of an audit, the MACs, CERT, SMRC, Recovery Auditors, and UPICs shall determine that an item/service is correctly coded. The document is broken into multiple sections. 03/11/2021: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. Beneficiaries Entering Medicare. The program covers drugs that are furnished "incident-to" a physician's service provided that the drugs are not "usually self-administered" by the patient. You . On a regular basis (even if there is no change in the order/prescription) only if it is so specified in the documentation section of a particular medical policy; When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order/prescription for the DMEPOS item from the transferring supplier. The medical history. If you are experiencing any technical issues related to the search, selecting the 'OK' button to reset the search data should resolve your issues. Information that is sufficiently detailed to unambiguously identify the specific product delivered to the beneficiary and the HCPCS code used to bill for that item must be maintained by the supplier and be available upon request. The key objectives of this initiative are: BEFORE: Suppliers could only ship immunosuppressive drugs to the patients home following an inpatient stay. copied without the express written consent of the AHA. Please review and accept the agreements in order to view Medicare Coverage documents, which may include licensed information and codes. Replacement of a beneficiary owned DMEPOS item typically involves providing an identical or nearly identical item. Documentation Requirements Documentation must support that the services billed were medically necessary and properly coded. An irreparable change in the condition of the device, or in a part of the device resulting in the need for a replacement; or. The license granted herein is expressly conditioned upon your acceptance of all terms and conditions contained in this agreement. Please Note: For Durable Medical Equipment (DME) MACs only, CPT/HCPCS codes remain located in LCDs. For some items, the initial justification for medical need establishes that the condition necessitating the item is permanent. website belongs to an official government organization in the United States. (not all-inclusive). The medical record is not limited to treating practitioners office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. This article sets out the general requirements that are applicable to all DMEPOS claims submitted to the DME MACs. The page could not be loaded. Consequently, the Durable Medical Equipment Medicare Administrative Contracts (DME MACs) have created guidance to assist Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) suppliers in understanding the information necessary to justify payment. Making copies or utilizing the content of the UB‐04 Manual, including the codes and/or descriptions, for internal purposes, All services that do not have appropriate POD from the supplier will be denied and overpayments will be requested. This revision is non-substantive. A supplier attestation that the item meets Medicare requirements. For items other than PMDs that appear on the Required List, the treating practitioner that conducted the face-to-face encounter does not need to be the prescriber for the DMEPOS item; however, the prescriber must: A qualifying face-to-face encounter is required each time a new order/prescription for one of the specified items on the Required List is ordered. This additional information is required so that the DME MACs can correctly process the claim. As used herein, "you" and "your" refer to you and any organization on behalf of which you are acting. Complying With Medical Record Documentation Requirements Fact Sheet Diabetic testing supplies (i.e., test strips, lancets), Parenteral and enteral administration kits, External infusion pump supplies (Recommended), Beneficiarys name or authorized representative if different from the beneficiary, A description of each item that is being requested. An item/service is correctly coded when it meets all the coding guidelines listed in CMS HCPCS guidelines, LCDs, LCD-related Policy Articles, or DME MAC articles. For services requiring a referring/ordering physician, the name and NPI of the referring/ordering physician must be reported on the claim. These R&N criteria are often referred to as medical necessity. The views and/or positions presented in the material do not necessarily represent the views of the AHA. PDF DOCUMENTATION CHECKLIST TOOL - CGS Medicare The responsibility for the content of this file/product is with CMS and no endorsement by the AMA is intended or implied. 04/02/2020: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. Failure to understand and document in accordance with payer and regulatory requirements can increase the risk for compliance audits, payment denials, and even legal issues. Share sensitive information only on official, secure websites. The program has several . Most DMEPOS accessory/supply items provided on a recurring basis can be dispensed with a three-month supply. The records document that all of the following basic criteria are met: The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home; AND Complying With Medical Record Documentation Requirements Fact Sheet Learn about proper medical record documentation requirments; how to provide accurate and supportive medical record documentation. The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely. Complete absence of all Bill Types indicates Try entering any of this type of information provided in your denial letter. 100-08), Chapter 3, Section 3.3.2.4. If you need more information on coverage, contact the Medicare Administrative Contractor (MAC) who published the document. Suppliers may use the date of delivery as the DOS on the claim. Medicare pays for one. No portion of the American Hospital Association (AHA) copyrighted materials contained within this publication may be Another option is to use the Download button at the top right of the document view pages (for certain document types). Draft articles are articles written in support of a Proposed LCD. If the information in the patient's medical record does not adequately support the medical necessity for the item, the supplier is liable for the dollar amount involved unless a properly executed Advance Beneficiary Notice of Noncoverage (ABN) of possible denial has been obtained. For these un-reviewed products, each supplier must use their best judgment in selecting HCPCS codes for billing and are encouraged to check with The PDAC Contact Center, which can provide information that will assist in correct code selection. Suppliers are required to correctly code for the item billed. Visit the Centers for Medicare & Medicaid Services (CMS) CERT webpage to review the Introduction to CERT presentation, Improper Payments Reports, CMS fact sheets, and more helpful tips. Physical Therapy Documentation of Patient and Client Management Documentation Checklist for Walkers - Noridian Medicare HCPCS code of related item (if applicable), A statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item, meets the POD requirements; and. For certain items of DMEPOS, a written order is required prior to delivery (WOPD) of the item(s) to the beneficiary (see below). Documentation Checklist for Positive Airway Pressure (PAP - Medicare Please contact your Medicare Administrative Contractor (MAC). Licensed Practical Nurses, social workers and case managers were added to the list which already included physician assistants, nurse practitioners, clinical nurse specialists, registered nurses and discharge planners. Supplier-produced records, even if signed by the treating practitioner, and attestation letters (e.g. U.S. Government rights to use, modify, reproduce, release, perform, display, or disclose these technical data and/or computer data bases and/or computer software and/or computer software documentation are subject to the limited rights restrictions of DFARS 252.227-7015 (b) (2) (June 1995) and/or subject to the restrictions of DFARS 227.7202-1 . without the written consent of the AHA. Medicare payment may be made for the replacement of prosthetic devices, which are artificial limbs, or for the replacement of any part of such devices, without regard to continuous use or useful lifetime restrictions if a treating practitioner determines that the replacement device, or replacement part of such a device, is necessary. Simplifying Documentation Requirements | CMS - Centers for Medicare Each supplier is ultimately responsible for the HCPCS code they select to bill for the item provided. CPT codes, descriptions and other data only are copyright 2022 American Medical Association. An asterisk (*) indicates a The quantities delivered and used by the beneficiary must justify the quantity billed. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential 06/15/2023: At this time 21st Century Cures Act applies to new and revised LCDs which require comment and notice. This information must be available upon request. We want to make documentation simpler for everyone. 2) Try using the MCD Search and enter your information in the "Enter keyword, code, or document ID" box. Use of CDT is limited to use in programs administered by Centers for Medicare & Medicaid Services (CMS). Medicare Part B Documentation Requirements Apr 30, 2019 / Article The following summarizes the documentation requirements required under Medicare Part B. For non-consumable supplies i.e., those more durable items that are not used up but may need periodic replacement (e.g., PAP and RAD supplies) the supplier must assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. This revision is to an article that is not a local coverage determination. However, routine periodic maintenance, such as testing, cleaning, regulating, and checking is not covered. Examples include but are not limited to, changes in beneficiary weight, changes in the residual limb, beneficiary functional need changes; or. Medical information intended to demonstrate compliance with coverage criteria may be included on the prescription but must be corroborated by information contained in the medical record.
