evekhm/cms_iom_500 huggingface dataset:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Before submitting a claim to Medicare, the DMEPOS supplier must have on file anSWO,a WOPD (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.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.Reimbursement shall be based on the specific utilization amount that is supported by contemporaneous medical records.Documentation must be maintained in the supplier's files for seven (7) years from DOS.If the Medicare qualifying supplier documentation is older than 7 years, proof of continuedmedical necessity of the item or necessity of the repaircan be used as the supporting Medicare qualifying documentation.REASONABLE AND NECESSARY CRITERIA (R&N)CMS National Coverage Determinations (NCDs) and contractor Local Coverage Determinations (LCDs) describe the requirements that must be met for an item to be considered R&N. These R&N criteria are often referred to as medical necessity.MEDICAL RECORD DOCUMENTATION
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
MEDICAL RECORD DOCUMENTATIONIn 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. 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. (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:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Supplier prepared statements and physician attestations by themselves do not provide sufficient documentation of medical necessity, even if signed by the ordering physician.Templates and forms are subject to corroboration with information in the medical record.A prescription is not considered to be part of the medical record, except in the case of documenting medical necessity for replacement prosthetic limbs. 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.The beneficiarys medical record must contain sufficient documentation of the beneficiarys medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the beneficiarys diagnosis and other pertinent information including, but not limited to, duration of the beneficiarys condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc.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.CONTINUED MEDICAL NEEDFor all DMEPOS items, the initial justification for medical need is established at the time the item(s) is first ordered; therefore, beneficiary medical records demonstrating that the item is reasonable and necessary are created just prior to, or at the time of, the creation of the initial prescription. For purchased items, initial months of a rental item or for initial months of ongoing supplies or drugs, information justifying reimbursement will come from this timeframe. Entries in the beneficiarys medical record must have been created prior to, or at the time of, the initial DOS to establish whether the initial reimbursement was justified based upon the applicable coverage policy.For ongoing supplies and rented DME items, in addition to information described above that justifies the initial provision of the item(s) and/or supplies, there must be information in the beneficiarys medical record to support that the item continues to remain reasonable and necessary. Information used to justify continued medical need must be timely for the DOS under review. Any of the following may serve as documentation justifying continued medical need:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
A recent order/prescription by the treating practitioner for refills of supplies;A recent order/prescription by the treating practitioner for repairs;A recent change in an order/prescription;Timely documentation in the beneficiarys medical record showing usage of the item.Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.For some items, the initial justification for medical need establishes that the condition necessitating the item is permanent. As a result, once the benefit category is met (or continues to be met), ongoing documentation of medical need is not required. Refer to the LCD-related Policy Articles for clarification regarding exceptions to ongoing justification for continued medical need.CONTINUED USEContinued use describes the ongoing utilization of supplies or a rented item by a beneficiary.Suppliers are responsible for monitoring utilization of DMEPOS rental items and supplies. No monitoring of purchased items or capped rental items that have converted to a purchase is required. Suppliers must discontinue billing Medicare when rental items or ongoing supply items are no longer being used by the beneficiary.Beneficiary medical records or supplier records may be used to confirm that a DMEPOS item continues to be used by the beneficiary. Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary:Timely documentation in the beneficiarys medical record showing usage of the item, related option/accessories and supplies;Supplier records documenting the request for refill/replacement of supplies in compliance with the REFILL DOCUMENTATION REQUIREMENTS section. This is deemed sufficient to document continued use for the base item, as well;Supplier records documenting beneficiary confirmation of continued use of a rental item.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in this policy.CLAIM NARRATIVESMost DMEPOS accessory/supply items provided on a recurring basis can be dispensed with a three-month supply. Please review the REFILL REQUIREMENTS section of each individual LCD for further details. When billing more than one month's supply of these items, include a narrative in the NTE segment of the electronic claim indicating the number of months you are billing. For example, if you bill a three-month supply of PAP accessories (i.e., mask, tubing, cushions), you must add "90-day supply" or "three-month supply". This additional information is required so that the DME MACs can correctly process the claim.DATE SPANS ON CLAIMSThe following DMEPOS items require a date span on all claims submitted to the DME MACs:Diabetic testing supplies (i.e., test strips, lancets)Continuous passive motion devices (CPM)Parenteral and enteral nutritionParenteral and enteral administration kitsExternal infusion pump supplies (Recommended)
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Diabetic testing supplies (i.e., test strips, lancets)Continuous passive motion devices (CPM)Parenteral and enteral nutritionParenteral and enteral administration kitsExternal infusion pump supplies (Recommended)Suppliers must span the dates of service using "From" and "To" dates on any electronic or paper claim for the items listed above. The "From" date is when the items were provided to the Medicare beneficiary. The "To" date is the last date the supplies are expected to be used. For example, if you are providing a three-month supply (January  March 2019) of diabetic testing supplies for a beneficiary, the "From" date on the claim would be "01/01/2019" and the "To" date would be "03/31/2019. This additional information is required so that the DME MACs can correctly process the claim.REFILL DOCUMENTATION REQUIREMENTSThis section contains general refill requirements that pertain to all policies. Refer to the applicable LCD for policy specific refill requirements.A routine prescription for refills is not needed.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.For items that are delivered to the beneficiary, documentation of a request for refill must be individualized to the beneficiary (i.e., the beneficiary or their caregiver/designee affirms the need for refill) and documented in the record. Medicare does not prescribe the mode of communication used to gather the information. For example, the refill request communication may be performed via automated text messaging or email as long as each required aspect of the refill request is captured. The refill request must occur and be documented before shipment. A retrospective attestation statement by the supplier or beneficiary is not sufficient.The refill record must include:Beneficiarys name or authorized representative if different from the beneficiaryA description of each item that is being requestedDocumentation of affirmative response indicating a need for refillDate of refill request
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
This information must be kept on file and be available upon request.PROOF OF DELIVERY (POD)42 CFR 424.57(c)(12) requires suppliers to maintain POD documentation in their files.POD documentation, as well as claims documentation, must be maintained in the suppliers files for 7 years (starting from the DOS).No billing may be made for any DMEPOS to the DME MAC prior to the date of discharge from an inpatient facility. A supplier may deliver a DME, prosthetics, or orthotics item (but not supplies) to a beneficiary in an inpatient facility that does not qualify as the beneficiarys home, for the purpose of fitting or training the beneficiary in the proper use of the item. This delivery may be done up to two (2) days prior to the beneficiarys anticipated discharge to their home. The supplier must bill the date of service on the claim as the date of discharge and the supplier must ensure that the beneficiary takes the item home, or the supplier picks up the item at the facility and delivers it to the beneficiarys home on the date of discharge. Any attempt by the supplier and/or facility to substitute an item that is payable to the supplier for an item that, under statute, should be provided by the facility, may be considered fraudulent.Suppliers, their employees, or anyone else having a financial interest in the delivery of the item(s) are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted on the delivery slip obtained by the supplier (i.e., spouse, neighbor). The signature of the designee should be legible. If the signature of the designee is not legible, the supplier/shipping service should note the name of the designee on the delivery slip.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.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
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 should also have on file any documentation containing a description of the item delivered to the beneficiary to determine the accuracy of claims coding including, but not limited to, a voucher, invoice or statement in the supplier records. A description of the items(s) delivered must be noted on the POD. 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.POD documentation must be available to the Medicare contractor on request. All services that do not have appropriate POD from the supplier will be denied and overpayments will be requested. Suppliers who consistently fail to provide documentation to support their services may be referred to the Office of Inspector General (OIG) or the National Supplier Clearinghouse for investigation and/or imposition of sanctions. As a general Medicare rule, the date of service shall be the date of delivery. There are three methods of delivery. Regardless of the method of delivery, the contractor must be able to determine that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) were received by a specific beneficiary:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Delivery directly to the beneficiary or authorized representativeDelivery via shipping or delivery serviceDelivery of items to a nursing facility on behalf of the beneficiaryMethod 1Direct Delivery to the Beneficiary by the SupplierSuppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery document. The POD document must include:Beneficiarys nameDelivery addressA description of the item(s) being 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 numberQuantity deliveredDate deliveredBeneficiary (or designee) signatureThe date delivered on the POD must be the date that the DMEPOS item was received by the beneficiary or designee. The date of delivery may be entered by the beneficiary, designee, or the supplier. When the suppliers delivery documents have both a supplier-entered date and a beneficiary or beneficiarys designee signature date on the POD document, the beneficiary (or designee) entered date is the DOS.In instances where the supplies are delivered directly by the supplier, the date the beneficiary received the DMEPOS supply must be the DOS on the claim.Method 2Delivery via Shipping or Delivery Service Directly to a BeneficiaryIf the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. An example of acceptable POD would include both the suppliers own detailed shipping invoice and the delivery services tracking information. The suppliers record must be linked to the delivery service record by some clear method like the delivery services package identification number or suppliers invoice number for the package sent to the beneficiary. The POD document must include:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Beneficiarys nameDelivery addressDelivery services package identification number, supplier invoice number, or alternative method that links the suppliers delivery documents with the delivery services recordsA description of the item(s) being 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 numberQuantity deliveredDate deliveredEvidence of deliveryIf a supplier utilizes a shipping service or mail order, suppliers have two options for the DOS to use on the claim:Suppliers may use the shipping date as the DOS. The shipping date is defined as the date the delivery/shipping service label is created or the date the item is retrieved by the shipping service for delivery. However, such dates should not demonstrate significant variation.Suppliers may use the date of delivery as the DOS on the claim.Suppliers may also utilize a return postage-paid delivery invoice from the beneficiary or designee as POD. This type of POD document must contain the information specified above.Method 3Delivery to Nursing Facility on Behalf of a BeneficiaryFor items directly delivered by the supplier to a nursing facility or when a delivery service or mail order is used to deliver the item(s) to a nursing facility, the supplier must have:Documentation demonstrating delivery of the item(s) to the facility by the supplier or delivery entity; and,Documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
CORRECT CODINGHealthcare Common Procedure Coding System (HCPCS) CODINGThe 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.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.The Pricing, Data Analysis, and Coding (PDAC) contractor maintains product listings for many HCPCS codes on theirwebsite(Select, DMECS to search for HCPCS codes and associated product lists). Not every HCPCS code has a product classification list; but reviewed products are added to the listings for each code as coding determinations are completed. For Medicare claim purposes, this product classification listing is accepted as evidence of correct coding.Each supplier is ultimately responsible for the HCPCS code they select to bill for the item provided. Resources such as LCDs, LCD-related Policy Articles, DME MAC articles, code determinations letters and DMECS are useful; but many products currently on the market have not been reviewed. 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.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.
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
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.Not Otherwise Classified (NOC) BILLING INFORMATIONItems billed with any HCPCS code with a narrative description that indicates miscellaneous, NOC, unlisted, or non-specified, must also include the following information in loop 2400 (line note), segment NTE02 (NTE01=ADD) of the ANSI X12N, version 5010A1 professional electronic claim format or on Item 19 of the paper claim form:
Article - Standard Documentation Requirements for All Claims Submitted to DME MACs (A55426)
Description of the item or serviceManufacturer nameProduct name and numberSupplier Price List (PL) amountHCPCS code of related item (if applicable)Miscellaneous HCPCS codes billed without this information will be rejected and will need to be resubmitted with the missing information included.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. ET, Monday through Friday. You may also visit the PDACwebsiteto chat with a representative or select the Contact Us button at the top of the page for email inquiry, FAX or postal mail information.EQUIPMENT RETAINED FROM A PRIOR PAYERWhen a beneficiary receiving a DMEPOS item from another payer (including a Medicare Advantage plan) becomes eligible for the Medicare Fee For Service (FFS) program, the first Medicare claim for that item or service is considered a new initial Medicare claim. Medicare does not automatically continue coverage for any item obtained from another payer when a beneficiary transitions to Medicare coverage.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.A POD is required for all items, even those in the beneficiarys possession provided by another insurer prior to Medicare eligibility.PROOF OF DELIVERY REQUIREMENTS FOR RECENTLY ELIGIBLE MEDICARE FFSThe supplier record must document:A statement, signed and dated by the beneficiary (or beneficiary's designee), that the supplier has examined the item, meets the POD requirements; andA supplier attestation that the item meets Medicare requirements.