LCD coverage policy updates

February 20, 2012

Why did this happen?

Due to the high CERT denials for multiple types of DME items the four Medical Directors decided that something had to be done to reduce these errors. Many of the errors were not medical necessity errors but processing errors on suppliers’ part.

The DME supplier is responsible for all areas of processing information that basically includes the online PIM (program integrity manual) as well as policy articles/LCDs/and DME MAC supplier manuals.

Many of the errors found were related to items that can be easily found in these resource errors.

The expanded “DOCUMENTATION REQUIREMENTS” was developed to put the majority of these resources in one area. Although many policies contain unique documentation requirements they have made these sections more readily available to help the supplier reduce their error rates.

Now you will see specific information related to the individual LCD as well as the STANDARD DOCUMENTATION REQUIREMENTS fully explained in this new format with references to the specific area of the online manual for you to research if you have a question.

1.     Prescription Requirements (PIM 5.2.2) when needed and what is needed.

2.    Dispensing Orders (PIM 5.2.2) also explains signature requirements as related to PIM 3.3.2.4

3.    Detailed Written Orders (PIM 5.2.3) what it is – when it is needed and what is required.

4.    Medical Record Information – reminder that supplier – produced records, even if signed by the ordering physician, 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.

5.    Continued * USE * IMPORTANT * – medical records OR supplier records MAY be used to confirm that DME continues to be used by the beneficiary

6.    Continued *NEED* initial – beneficiary records show at time of or “JUST” prior to the order demonstrates need for the item as reasonable and necessary.     

*Purchased items, initial months of rental or for INITIAL months of ongoing supplies or drugs, initial time period. (MUST be seen by the ordering physician “just” prior to) Entries created prior to or at time of initial DOS. Ongoing and rentals must have information of continued “NEED” – recent order/recent change in RX/properly completed CMN or DIF with appropriate LON specified.

*Timely Documentation is defined as recorded in the preceding 12 months unless otherwise specified elsewhere in the policy.

7.    Refill documentation (PIM  5.2.5-6) OPTIONAL when needed and what is needed

8.    Proof of delivery (PIM 4.26, 5.8) when needed and what is needed and three different methods discussed.  

9.    Policy specific requirements (PIM 5.3) OPTIONAL

10.    DIF form (PIM 5.3)  OPTIONAL

11.    CMNs  (OIM 5.3) OPTIONAL

12.    Repair / Replacement (BPM CH 15, 100.2) what is needed – records – replacement

Click here for article from DME MAC Jurisdiction C News