What are the documents should DME billing provider maintain?

DOCUMENTATION REQUIREMENTS

A. Supplier/provider records must substantiate the medical necessity for all DMEPOS items dispensed to recipients. The following describes the requirements for specific types of documentation associated with DMEPOS.

1. ORDERS / PRESCRIPTIONS

a. All DME items, Prosthetics, Orthotics, or Disposable Supplies (POS) dispensed must have an order/prescription from the treating physician or practitioner, (To determine included practitioners, refer to MSM, Chapter 600 – Physician’s Services), such as a Physician’s Assistant (PA), or Advanced Practitioner of Nursing (APN), when within their scope of practice and in accordance with federal and state laws governing that entity, prior to dispensing the item.

In accordance with the Patient Protection and Affordable Care Act (PPACA) (The Affordable Care Act) of 2010 (Public Law 111-148), all orders for DMEPOS items, whether verbal or written, must be incidental to a physician-documented face-to-face encounter between the recipient and the prescribing physician/practitioner (as allowed by The Act) within 30 days prior to the start date of the order. The encounter must be relevant to the need for the prescribed DMEPOS.

Refer to Appendix B of this Chapter for additional order requirements on specific products.

General standards of care/practice mandate that if an order is not clear, a clarification of the order must be obtained from the ordering practitioner prior to acting on it.
b. Verbal Orders:
c. Written Orders

2. DETAILED PRODUCT DESCRIPTION

The detailed product description must contain the Healthcare Common Procedure Coding System (HCPCS) code, manufacturer, make and model, and the provider’s/supplier’s usual and customary charge for each item supplied. The warranty information must also be included. This may be completed by the provider/supplier but must also be signed and dated by the physician.

3. PROOF OF DELIVERY (POD) A POD is a supplier’s delivery receipt, which is dated and timed.

NOTE: Item(s) ordered must be delivered within 120 days of the date of the order.


4. ADDITIONAL MISCELLANEOUS MEDICAL RECORDS

The recipient’s medical records must contain sufficient documentation of the recipient’s medical condition to substantiate the necessity for the type and quantity
of items ordered and the frequency of the use or replacement. The information must include the recipient’s diagnosis and other pertinent information, including
but not limited to: duration of recipient’s condition, clinical course (deteriorating or improving), prognosis, nature and extent of functional limitations, other
therapeutic interventions and results, past experience with related items, etc. The records must include physician’s office records, hospital, nursing home or home
health records, records from other professionals including but not limited to: nursing, physical and occupational therapists, prosthetists and orthotists, although
medical necessity for item(s) requested must be stated by the prescribing physician/practitioner.

5. ADVANCED DETERMINATION OF MEDICARE COVERAGE (ADMC)

When Medicare is the primary payer, for all items requiring an ADMC (refer online to the DME MAC Jurisdiction D, Supplier Manual, Chapter 9). The ADMC determination must be submitted to the Quality Improvement Organization (QIO)- like vendor at the same time the prior authorization is submitted.