(Medicare Claims Processing Manual)

The acceptance of an assignment binds the supplier -assignee to accept the allowed charge for the medically required equipment or service as the full charge and he cannot charge the beneficiary the differential attributable to the equipment actually furnish ed.  Only if a more expensive item or model with special features is medically necessary for the beneficiary will the allowed charge be based on the more expensive model.  If the patient purchases or rents an item of durable medical equipment having more expens ive features than his condition requires, the supplier accepting assignment on such an item cannot charge or collect any amount in excess of the allowed charge for the appliance adequate for the patient's needs.  Acceptance of assignment binds the supplier  to accept the allowed charge determined by the DME MAC, as the full charge for the item.  A supplier who wishes to charge and collect the full price for equipment more expensive than medically required by the patient need not accept assignment.  In assignment cases, the beneficiary is responsible for paying the supplier the unpaid balance of the allowed charge when payments stop because his condition has changed and the equipment is no longer medically necessary.  Similarly, when payments stop because the beneficiary dies, his/her estate is responsible to the supplier for such unpaid balance.   100 - General Documentation Requirements  (Rev. 11414; Issued: 05- 12-22; Effective: 06 -13-22; Implementation: 06 -13-22) NOTE: CMS seeks to reduce burden and modernize processes to ensure a reduction in improper payments and an increase in customer satisfaction. The Certificate of Medical Necessity (CMN) form and DME Information Form (DIF) were originally required to help document  the medical necessity and other coverage criteria for selected Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items. In the past, a supplier received a signed CMN from the treating physician or created and signed a DIF to submit with the claim. Due to improvements in claims processing and medical records management, the information found on CMNs or DIFs is available either on the claim or in the medical record and is redundant. Therefore, to reduce burden and increase custom er satisfaction, providers and suppliers no longer need to submit these forms for services rendered after January 1, 2023.   For claims with dates of service on or after January 1, 2023  providers and suppliers no longer need to submit CMNs or DIFs with claims. Due to electronic filing requirements, claims received with these forms attached will be rejected and returned to the provider or supplier.   For claims with dates of service prior to January 1, 2023  processes will not change and if the CMN or DIF is required, it will still need to be submitted with the claim, or be on file with a previous claim.  This statement applies throughout the Program Integrity Manual wherever CMNs and DIFs are mentioned.   B3-4107.1, B3- 4107.8, HHA -463, Medicare Handbook for New Suppliers: Getting Started, B -02-31  Benefit policies are set forth in the Medicare Benefit Policy Manual, Chapter 15, 110-130.  Program integrity policies for DMEPOS are set forth in the Medicare Program Integrity Manual, Chapter 5.   See Chapter 21 for applicable MSN messages.   See Chapter 22 for Remittance Advice coding.   100.1 - Written Order Prior to Delivery  (Rev. 1, 10- 01-03)  See the Medicare Program Integrity Manual, Chapter 5, for requirements for written orders for suppliers, including providers billing the DME MAC or A/B MAC (B) as suppliers.  See  01 for definitions of provider and supplier.   100.1.1 - Written Order Prior to Delivery - HHAs  (Rev. 1, 10- 01-03)  See the Medicare Program Integrity Manual, Chapter 6.  These instructions apply to bill types 32x, 33x and 34x.   100.2 - Certificates of Medical Necessity (CMN)  (Rev. 1, 10- 01-03) B3-3312  For certain items or services billed to the DME MAC, the supplier must receive a signed Certificate of Medical Necessity (CMN) from the treating physician.  CMNs are not required for the same items when billed by HHAs to A/B MACs (HHH).  Instead, the items must be inc luded in the physician's signed orders on the home health plan of care.  See the Medicare Program Integrity Manual, Chapter 6.  The A/B MAC (A) will inform other providers (see 01 for definition pf provider) of documentation requirements.  DME MACs may ask for supporting documentation beyond a CMN.   Refer to the DME MAC Web site described in 10 for downloadable copies of CMN forms.   See the Medicare Program Integrity Manual, Chapter 5, for specific Medicare policies and instructions on the following topics:    Requirements for supplier retention of original CMNs   CMN formats, paper and electronic   List of currently approved CMNs and items requiring CMNs   Supplier requirements for submitting CMNs   Requirements for CMNs to also serve as a physician's order   Civil monetary penalties for violation of CMN requirements   Supplier requirements for completing portions of CMNs   Physician requirements for completing portions of CMNs   100.2.1 - Completion of Certificate of Medical Necessity Forms (Rev. 4202, Issued: 01- 18-19, Effective: 02 -19-19, Implementation: 02- 19-19)  The term Medicare beneficiary identifier (Mbi) is a general term describing a beneficiarys Medicare identification number. For purposes of this manual, Medicare beneficiary identifier references both the Health Insurance Claim Number (HICN) and the Medicare Beneficiary Identifier (MBI) during the new Medicare card tran sition period and after for certain business areas that will continue to use the HICN as part of their processes.   1. SECTION A: (This may be completed by supplier.)   a. Certification Type/Date - If this is an initial certification for this patient, the date (MM/DD/YY) is indicated in the space marked "INITIAL".  If this is a revised certification (to be completed when the physician changes the order, based on the patient' s changing clinical needs), the initial date is indicated in the space marked "INITIAL", and the revision date is indicated in the space marked "REVISED".  If this is a recertification, the initial date is indicated in the space marked "INITIAL", and the r ecertification date is indicated in the space marked "RECERTIFICATION".  Whether a REVISED or RECERTIFIED CMN is submitted, the INITIAL date as well as the REVISED or RECERTIFICATION date is always furnished.   b. Patient Information -  This indicates the patient's name, permanent legal address, telephone number, and his/her Medicare beneficiary identifier as it appears on his/her Medicare card and on the claim form.   c. Supplier Information -  This indicates the name of the company (supplier name), address, telephone number, and the Medicare supplier number assigned by the National Supplier Clearinghouse (NSC).  d. Place of Service -  This indicates the place in which the item is being used, i.e., patient's home is 12, skilled nursing facility (SNF) is 31, or end stage renal disease (ESRD) facility is 65.  See chapter 23 for place of service codes.   e. Facility Name - This indicates the name and complete address of the facility, if the place of service is a facility.   f. HCPCS Codes -  This is a list of all HCPCS procedure codes for items ordered that require a CMN.  Procedure codes that do not require certification are not listed on the CMN.  g. Patient Date of Birth (DOB), Height, Weight, and Sex -  This indicates patient's DOB (MM/DD/YY), height in inches, weight in pounds, and sex (male or female).   h. Physician Name and Address -  This indicates the treating physician's name and complete mailing address.   i. UPIN - This indicates the treating physician's unique physician identification number (UPIN).   j. Physician's Telephone Number -  This indicates the telephone number where the treating physician can be contacted (preferably where records would be accessible pertaining to this patient) if additional information is needed.   2. SECTION B: (This may not be completed by the supplier.  While this section may be completed by a non -physician clinician, or a physician employee, it must be reviewed by the treating physician.  A/B MACs (B) and (HHH) and DME MACs publish this requirement about section B in their bulletins at least annually.)   a. Estimated Length of Need -  This indicates the estimated length of need (the length of time (in months) the physician expects the patient to require use of the ordered item).  If the treating physician expects that the patient will require the item for the duration of his/her life, 99 is entered.  For recertification and revision CMNs, the cumulative length of need (the total length of time in months from the initial date of need) is entered.   k. Diagnosis  Codes -  Listed in the first space is the diagnosis code that represents the primary reason for ordering this item.  Additional diagnosis codes that would further describe the medical need for the item (up to 3 codes) are also listed.  A given CMN may have more than one item billed, and for each item, the primary reason for ordering may be different.  For example, a CMN is submitted for a manual wheelchair (K0001) and elevating leg rests (K0195).  The primary reason for K0001 is stroke, and the pri mary reason for K0195 is edema.   l. Question Section -  This section is used to gather clinical information regarding the patient's condition, the need for the DME, and supplies.  m. Name of Person Answering Section B Questions -  If a clinical professional other than the treating physician (e.g., home health nurse, physical therapist, dietician, or a physician employee) answers the questions in section B, he/she must print  his/her name, give his/her professional title, and the name of his/her employer, where indicated.  If the treating physician answered the questions, this space may be left blank.   3. SECTION C: (This is completed by the supplier.)   a. Narrative Description of Equipment and Cost -  The supplier indicates (1) a narrative description of the item(s) ordered, as well as all options, accessories, supplies, and drugs; (2) the supplier's charge for each item, option, accessory, supply, and drug;  and (3) the Medicare fee schedule allowance for each item, option, accessory, supply, or drug, if applicable.   4. SECTION D: (This is completed by the treating physician.)   a. Physician Attestation -  The treating physician's signature certifies the CMN that he/she is reviewing includes sections A, B, C, and D, the answers in section B are correct, and the self -identifying information in section A is correct.  b. Physician Signature and Date -  After completion and/or review by the treating physician of sections A, B, and C, the treating physician must sign and date the CMN in section D, verifying the attestation appearing in this section.  The treating physician's signature also certifies the items ordered are medically necessary for this patient.  Signature and date stamps are not acceptable.   Certifications and recertifications may not be altered by "whiting out" or "pasting over" and entering new data.  Such claims are denied and suppliers that show a pattern of altering CMNs are identified for educational contact and/or audit.   Also suppliers who have questionable utilization or billing practices or who are under sanction are considered for audit.  100.2.2 - Evidence of Medical Necessity for Parenteral and Enteral Nutrition (PEN) Therapy  (Rev. 1, 10- 01-03) B3-3324, B3- 4450  The PEN coverage is determined by information provided by the treating physician and the PEN supplier.  A completed certification of medical necessity (CMN) must accompany and support initial claims for PEN to establish whether coverage criteria are met an d to ensure that the PEN therapy provided is consistent with the attending or ordering physician's prescription.  DME MACs ensure that the CMN contains pertinent information from the treating physician.  Uniform specific medical data facilitate the review and promote consistency in coverage determinations and timelier claims processing.   The medical and prescription information on a PEN CMN can be most appropriately completed by the treating physician or from information in the patient's records by an employee of the physician for the physician's review and signature.  Although PEN suppliers sometimes may assist in providing the PEN services, they cannot complete the CMN since they do not have the same access to patient information needed to properly enter medical or prescription information.  A/B MACs (B) and DME MACs use appropriate professional relations issuances, training sessions, and meetings to ensure that all persons and PEN suppliers are aware of this limitation of their role.   When properly completed, the PEN CMN includes the elements of a prescription as well as other data needed to determine whether Medicare coverage is possible.  This practice will facilitate prompt delivery of PEN services and timely submittal of the related  claim.