For any Durable Medical Equipment, Prosthetic, Orthotic and Supply (DMEPOS) item to be covered by Medicare, the patient's medical record must contain sufficient information about the patient's medical condition to substantiate the necessity for the type of equipment or supply, quantity and/or frequency of use or replacement, if applicable.
Full Answer
What are the medical necessity requirements for DMEPOS?
Keep unaltered DMEPOS prescriptions and Certificates of Medical Necessity (CMNs) in the patient’s record The patient’s record must contain information that helps determine medical necessity, including: Deliver loaner equipment while original is under repair (except orthotics/prosthetics)
What does DMEPOS stand for?
Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) suppliers must meet the Centers for Medicare & Medicaid Services (CMS) DMEPOS Quality Standards under the Medicare Modernization Act of 2003 (MMA).
What information must be in a patient’s record?
The patient’s record must contain information that helps determine medical necessity, including: Deliver loaner equipment while original is under repair (except orthotics/prosthetics) Ensure equipment is consistent with the prescriber’s order and the patient’s needs Deliver the equipment in the time scheduled.
What medical records are not part of a medical record?
Supplier-produced records, even if signed by the prescribing physician/practitioner, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. Templates and forms, including CMS CMNs, are subject to corroboration with information in the medical record.
What are the medical necessity documentation requirements?
Well, as we explain in this post, to be considered medically necessary, a service must:“Be safe and effective;Have a duration and frequency that are appropriate based on standard practices for the diagnosis or treatment;Meet the medical needs of the patient; and.Require a therapist's skill.”
Which CMS publications provide medical necessity guidelines?
ResourcesCMS Internet Only Manual (IOM), Publication 100-08, Medicare Program Integrity Manual, Chapter 13, Local Coverage Determinations.American Medical Association (AMA) Current Procedural Terminology (CPT) Manual.Healthcare Common Procedure Coding System (HCPCS) Manual.
What does Dmepos mean?
DMEPOS stands for durable medical equipment, prosthetics, orthotics and supplies. Page 2. DMEPOS supplier means an entity or individual, including a physician or a Part A provider, which sells or rents Part B covered items to Medicare beneficiaries and which meets the standards in paragraphs (c) and (d) of this section ...
What are Dmepos items?
DMEPOS = Durable Medical Equipment, Prosthetics, Orthotics and Supplies.
How do you determine medical necessity?
How is “medical necessity” determined? A doctor's attestation that a service is medically necessary is an important consideration. Your doctor or other provider may be asked to provide a “Letter of Medical Necessity” to your health plan as part of a “certification” or “utilization review” process.
What does CMS say about medical necessity?
Medical Necessity - Rehabilitation Services must be under accepted standards of medical practice and considered to be specific and effective treatment for the patient's condition. The amount, frequency, and duration of the services planned and provided must be reasonable.
What is Dmepos accreditation?
They validate suppliers meet all supplier standards, validate the supplier is properly accredited for the products and services they note on their enrollment application, and maintain a DMEPOS supplier enrollment central data information repository.
What are Medicare Supplier standards?
A supplier must not charge the beneficiary or the Medicare program for the repair or replacement of Medicare covered items or for services covered under warranty. This standard applies to all purchased and rented items, including capped rental items, as described in §414.229 of this subchapter.
What medical supplies Does Medicare pay for?
DME that Medicare covers includes, but isn't limited to:Blood sugar meters.Blood sugar test strips.Canes.Commode chairs.Continuous passive motion devices.Continuous Positive Airway Pressure (CPAP) devices.Crutches.Hospital beds.More items...
Where are Dmepos claims submitted to?
DMEPOS claims are submitted to DME Medicare administrative contractors (DME MACs) that replace durable medical equipment regional carriers (or DMERCs) that are awarded contracts by CMS.
How do you write a prescription for DME?
Your prescription can be handwritten on a standard prescription pad. It must include the physician's name, contact information and signature of the care provider; your name; and a statement about the equipment needed, for example "Oxygen at LPM" “CPAP” , “BiPAP”, “CPAP Mask”, “CPAP Humidifier” or “CPAP Supplies”.
What is a standard written order?
Standard Written Order (SWO) All claims for items billed to Medicare require a written order/prescription from the treating practitioner as a condition for payment. This written order/prescription is referred to as the Standard Written Order (SWO). / Beneficiary's name or Medicare Beneficiary Identifier (MBI)
Which of the following medical record documentation templates is organized by the entity?
NHA CCMAQuestionAnswerWhat medical record documentation template is organized by the entity that supplied the data?Source-orientedA MA is preparing a 1 g/kg of activated charcoal for a pt who weighs 176 ib. How many grams of charcoal should be prepared?79 g. To convert lb to kg, multiply the lb by 0.45.172 more rows
Which member of the medical practice is ultimately responsible for proper documentation and correct coding?
Which member of the medical practice is ultimately responsible for proper documentation and correct coding? Ultimately, the physician is responsible for proper documentation and correct coding.
What is an example of medical necessity?
The most common example is a cosmetic procedure, such as the injection of medications, such as Botox, to decrease facial wrinkles or tummy-tuck surgery. Many health insurance companies also will not cover procedures that they determine to be experimental or not proven to work.
What does CMS say about copy and paste?
Don't copy and paste excessive, extraneous information. CMS does not reward volume of documentation.
What is contemporaneous medical record?
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. The medical record is not limited to treating physician/practitioner's office records but may include records from hospitals, nursing facilities, home health agencies, other healthcare professionals, etc. (not all-inclusive). Records from suppliers or healthcare professionals with a financial interest in the claim outcome are not considered sufficient by themselves for determining that an item is reasonable and necessary. DMEPOS suppliers are reminded that: 1 Supplier-produced records, even if signed by the prescribing physician/practitioner, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes. 2 Templates and forms, including CMS CMNs, are subject to corroboration with information in the medical record. 3 A prescription is not considered to be part of the medical record. 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.
What information is included on a prescription?
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. In addition to the general requirements discussed above, certain DMEPOS items may have specific documentation requirements.
What is consent to monitoring?
Consent to Monitoring. Warning: you are accessing an information system that may be a U.S. Government information system. If this is a U.S. Government information system, CMS maintains ownership and responsibility for its computer systems. Users must adhere to CMS Information Security Policies, Standards, and Procedures.
Does DMEPOS have specific documentation requirements?
In addition to the general requirements discussed above, certain DMEPOS items may have specific documentation requirements. Details regarding these policy specific requirements are contained in the applicable LCD-related Policy Article.
Is a supplier's medical record a Medicare payment?
Supplier-produced records, even if signed by the prescribing physician/practitioner, and attestation letters (e.g. letters of medical necessity) are deemed not to be part of a medical record for Medicare payment purposes.
Does Medicare require a medical record?
The Medicare program does not have requirements for the media formats for medical records. However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities. Providers must have a medical record system that ensures that the record may be accessed and retrieved promptly.
Do medical records need to be in original form?
However, the medical record needs to be in its original form or in a legally reproduced form, which may be electronic, so that medical records may be reviewed and audited by authorized entities. Providers must have a medical record system that insures that the record may be accessed and retrieved promptly.". Resource.
What is the information on a surgical report?
information is date of surgery, patient i.d., pre and post-op diagnosis, list of procedures performed, and names of primary and secondary surgeons.
What is the term for CMS rules?
Rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations ( LCDs).
What is Medicare Coverage Database?
Used by Medicare administrative contractors, providers, and other healthcare industry professionals to determine whether a procedure or service is reasonable and necessary for the diagnosis or treatment of an illness or injury; contains national coverage determinations ...
What is medical managed?
Medical Managed. A particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider has to consider that diagnosis when considering treatment for other conditions. Medicare Coverage Database. Used by Medicare administrative contractors, providers, and other healthcare industry professionals ...
What is the diagnosis with the procedure/service?
the diagnosis with the procedure/service is to prove medical necessity.
What is UB-04 in medical billing?
Review of patient records and CMS-1500 (UB-04) claims to assess coding accuracy and whether documentation is complete.
Can hypertension be treated at an office visit?
A particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider has to consider that diagnosis when considering treatment for other conditions.
What is a DMEPOS in Medicare?from cms.gov
All Medicare-covered DMEPOS must have a medical purpose and may require the prescribing physician to coordinate clinical services with other health care professionals (for example, orthotists, prosthetists, occupational, physical, and respiratory therapists, and pedorthists).
How many sections are there in DMEPOS?from cms.gov
The DMEPOS Quality Standards have two sections and three appendices:
What does a DMEPOS supplier have to offer?from cms.gov
4. The supplier must offer only DMEPOS and other items that meet applicable FDA regulations and medical device effectiveness and safety standards. The manufacturer must give the supplier copies of the features, warranties, and instructions for each type of item not custom fabricated.
What is the term for CMS rules?from quizlet.com
Rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations ( LCDs).
Why is it important to have a documenation of all health care services provided to the patient?from quizlet.com
important to the health care facility because it contains documenation of all health care services provided to the patient and supports the following: diagnosis, justifies treatment, and records treatment results.
What is medical managed?from quizlet.com
Medical Managed. A particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider has to consider that diagnosis when considering treatment for other conditions. Medicare Coverage Database. Used by Medicare administrative contractors, providers, and other healthcare industry professionals ...
What is the requirement for a supplier to keep patient records?from cms.gov
The supplier must keep accurate, pertinent, accessible, confidential, and secure patient records required by the HIPAA privacy and security standards and other applicable State standards.
What is DMEPOS in Medicare?from cms.gov
Suppliers who receive Medicare reimbursement for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are required to: If your business doesn’t dispense or furnish DMEPOS, you should use the Medicare Enrollment Guide for Providers & Suppliers.
What information do you need to submit a DMEPOS claim to Medicare?from cms.gov
Before submitting a claim to Medicare, the DMEPOS supplier must have on file SWO, a WOPD (if applicable), a CMN (if applicable), a DIF (if applicable), information from the treating practitioner concerning the patient's diagnosis, and any information required for the use of specific modifiers or attestation statements as defined in certain DME MAC policies. 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. 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.
What is replacement of beneficiary owned DMEPOS item?from cms.gov
Replacement of a beneficiary owned DMEPOS item typically involves providing an identical or nearly identical item.
What is correct HCPCS code?from cms.gov
Correct HCPCS coding is a determination that the item provided to a beneficiary is billed using the appropriate HCPCS code for that item. Suppliers are required to correctly code for the item billed. 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.
What is the authority of CMS to establish HCPCS level 2?from cms.gov
The Medicare Program Integrity Manual (CMS Pub. 100-08), Chapter 3, Sections 3.3.B and 3.6.2.4 specify that for Medicare claims, only CMS and the Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have the authority to establish HCPCS Level II Coding Guidelines. Pursuant to 42 CFR § 414.40 and 45 CFR § 162.1002, CMS has the authority to assign and manage HCPCS codes (create, delete, change code narrative etc.). The DME MACs have the authority to evaluate products to make benefit category and coding determinations for any DME item that does not logically fall into any of the generic categories listed in NCD 280.1.
What is CMS requirement?from cms.gov
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 supplier must have on file a description of items provided to the beneficiary in sufficient detail to determine the accuracy of claims coding including a description of the items (s) delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number.
What is CMS in healthcare?from cms.gov
The Centers for Medicare & Medicaid Services (CMS), the federal agency responsible for administration of the Medicare, Medicaid and the State Children's Health Insurance Programs, contracts with certain organizations to assist in the administration of the Medicare program. Medicare contractors are required to develop and disseminate Articles. CMS believes that the Internet is an effective method to share Articles that Medicare contractors develop. While every effort has been made to provide accurate and complete information, CMS does not guarantee that there are no errors in the information displayed on this web site. THE UNITED STATES GOVERNMENT AND ITS EMPLOYEES ARE NOT LIABLE FOR ANY ERRORS, OMISSIONS, OR OTHER INACCURACIES IN THE INFORMATION, PRODUCT, OR PROCESSES DISCLOSED HEREIN. Neither the United States Government nor its employees represent that use of such information, product, or processes will not infringe on privately owned rights. In no event shall CMS be liable for direct, indirect, special, incidental, or consequential damages arising out of the use of such information, product, or process.
What is a DMEPOS in Medicare?from cms.gov
All Medicare-covered DMEPOS must have a medical purpose and may require the prescribing physician to coordinate clinical services with other health care professionals (for example, orthotists, prosthetists, occupational, physical, and respiratory therapists, and pedorthists).
How many sections are there in DMEPOS?from cms.gov
The DMEPOS Quality Standards have two sections and three appendices:
What does a DMEPOS supplier have to offer?from cms.gov
4. The supplier must offer only DMEPOS and other items that meet applicable FDA regulations and medical device effectiveness and safety standards. The manufacturer must give the supplier copies of the features, warranties, and instructions for each type of item not custom fabricated.
What is the term for CMS rules?from quizlet.com
Rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations ( LCDs).
Why is it important to have a documenation of all health care services provided to the patient?from quizlet.com
important to the health care facility because it contains documenation of all health care services provided to the patient and supports the following: diagnosis, justifies treatment, and records treatment results.
What is medical managed?from quizlet.com
Medical Managed. A particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider has to consider that diagnosis when considering treatment for other conditions. Medicare Coverage Database. Used by Medicare administrative contractors, providers, and other healthcare industry professionals ...
What is the requirement for a supplier to keep patient records?from cms.gov
The supplier must keep accurate, pertinent, accessible, confidential, and secure patient records required by the HIPAA privacy and security standards and other applicable State standards.
What is a DMEPOS in Medicare?from cms.gov
All Medicare-covered DMEPOS must have a medical purpose and may require the prescribing physician to coordinate clinical services with other health care professionals (for example, orthotists, prosthetists, occupational, physical, and respiratory therapists, and pedorthists).
How many sections are there in DMEPOS?from cms.gov
The DMEPOS Quality Standards have two sections and three appendices:
What does a DMEPOS supplier have to offer?from cms.gov
4. The supplier must offer only DMEPOS and other items that meet applicable FDA regulations and medical device effectiveness and safety standards. The manufacturer must give the supplier copies of the features, warranties, and instructions for each type of item not custom fabricated.
What is the term for CMS rules?from quizlet.com
Rules developed by CMS that specify under what clinical circumstances a service or procedure is covered (including clinical circumstances considered reasonable and necessary) and correctly coded; Medicare administrative contractors create edits for NCD rules, called local coverage determinations ( LCDs).
Why is it important to have a documenation of all health care services provided to the patient?from quizlet.com
important to the health care facility because it contains documenation of all health care services provided to the patient and supports the following: diagnosis, justifies treatment, and records treatment results.
What is medical managed?from quizlet.com
Medical Managed. A particular diagnosis (e.g., hypertension) may not receive direct treatment during an office visit, but the provider has to consider that diagnosis when considering treatment for other conditions. Medicare Coverage Database. Used by Medicare administrative contractors, providers, and other healthcare industry professionals ...
What is the requirement for a supplier to keep patient records?from cms.gov
The supplier must keep accurate, pertinent, accessible, confidential, and secure patient records required by the HIPAA privacy and security standards and other applicable State standards.
Who issues NCDs?
NCDs are issued by the Centers for Medicare & Medicaid Services (CMS) at the national level —– meaning the policies apply to all Medicare providers. LCDs are issued by Medicare administrative contractors (MACs) or other payers at the local level.
Is medical necessity a secret?
Proving medical necessity is really no secret at all: Medicare national coverage determinations (NCDs) and local coverage determinations (LCDs) dictate which diagnosis codes must be documented by clinicians to support the medical necessity of most services or supplies they provide to patients. Coders who are informed of these policies play an ...