MEDICARE DOCUMENTION REQUIREMENTS

THE BASICS

Most medical equipment is covered by Medicare when the patient has a documented medical necessity that can be resolved with the item. The challenge is that Medicare requires very specific items to be addressed in the medical record.

The following is a primer on what is required for most orders.

THE FACE TO FACE EXAMINATION

The patient must have been seen by a physician, for the condition that is causing the needs for the medical device, within the last six months.

Before a piece of medical equipment can be ordered the patient must have been seen by a physician, physician’s assistant, registered nurse practitioner, or a clinical nurse specialist.

This examination must occur within the six months prior to ordering the medical device. It needs to be signed by the physician. If the exam was conducted by a P.A., Rn.P., or C.N.S., then the supervising physician must also sign off on the

Tip: When medical equipment is being ordered the patient has generally been seen by a doctor within the past six months. We’re often able to use this exam to satisfy the Face to Face requirement.

PROGRESS NOTES & ADDENDUMS

When the Face to Face examination does not discuss the items required for coverage, the clinician may be able to address the missing information by using a progress note or addendum.

Progress Notes

A Progress Note is often prepared by a nurse or other clinician that is part of the patients care team. These notes become part of the medical record and are therefore acceptable by Medicare. In certain circumstances the clinician may see circumstances in the home environment that, when documented, can address the coverage requirements.

The Addendum

When a physician is examining a patient he or she will document what they deem to be necessary in the patient’s chart. These entries may not address all of the requirements for coverage of the item being ordered.

In these cases the physician can add to their examination report by using an addendum. The purpose of the addendum is to add additional information to the report that was observed by the physician, but not specifically noted. They can also be used to clarify the doctor’s notes where they appear to be vague.

DETAILED WRITTEN ORDERS

Prescriptions for medical equipment are required to contain several specific items that are not present on most common prescriptions. Further, the DWO must be signed and dated prior to delivery of the item.

A DWO must contain:

The patient’s name
The patient’s HIC Number
An item description (with HCPCS code)
A description of any accessories being ordered (with HCPCS code)
Directions for use (when appropriate)
Prescriber’s Signature
The Prescriber’s NPI number (individual, not group)

CERTIFICATES OF MEDICAL NECESSITY ,TESTING AND OTHER ITEMS

SOME ITEMS REQUIRE OTHER DOCUMENTION SUCH AS TESTING OR A CERTIFICATE OF MEDICAL NECESSITY (CMN).

Oxygen CMN

Oxygen equipment requires a Certificate of Medical Necessity. This form can be downloaded here. If we receive an oxygen order that is missing the CMN we’ll partially prepare the document and return it to your office for completion and signature.

Oxygen Testing

In addition to the examination requirements, oxygen therapy requires that testing is performed.  The test may be either pulse oximetry, or an arterial blood gas (ABG). There are specific requirements for this testing. Please see our article titled “Qualifying for Oxygen Therapy”.

Enteral Nutrition

Prescriptions for enteral nutrition must include a failed swallow test.