● Certain DME Healthcare Common Procedure Coding System (HCPCS) codes (such as, hospital beds, glucose monitors, and manual wheelchairs) require a valid detailed written order prior to delivery, per MLN Matters® Article MM8304 ● The physician’s National Provider Identifier (NPI) must be on the valid detailed written order ● Medicare will pay claims only for DME if the ordering physician and DME supplier are actively enrolled in Medicare on the date of service ● As a condition for payment, a physician, Physician Assistant (PA), Nurse Practitioner (NP), or Certified Nurse Specialist (CNS) must document a face-to-face encounter examination with a beneficiary in the 6 months prior to the written order for certain items of DME
Full Answer
What are the documentation requirements for the DME Mac?
Durable Medical Equipment (DME) Certain DME Healthcare Common Procedure Coding System (HCPCS) codes (such as, hospital beds, glucose monitors, and manual wheelchairs) require a valid detailed written order prior to delivery, per MLN Matters® Article MM8304 The physician’s National Provider Identifier (NPI)
What are the supporting documentation requirements for the DMEPOS?
Jan 01, 2017 · 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 …
How long do I need to keep documentation for Medicare qualifying items?
with Medicare coverage is required, upon request, in order to validate: • The site of service; • The medical necessity and appropriateness of the supplies, equipment, and services provided; and/or • That items furnished have been accurately reported. • All documentation must be maintained for seven years and be available upon request.
What are the documentation requirements for Medicare reimbursement for a repair?
An authorized site inspector, whether an NSC employee or a contractor, will have a photo identification card and a signed letter on CMS letterhead authorizing the individual to conduct the visit with them. Please note, the inspector will have a camera to take various pictures of the facility, sign, inventory, etc.
What are the documentation guidelines for DME?
Documentation, including pertinent portions of the beneficiary's medical records (e.g., history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans), supporting the medical necessity of the prescribed PMD must be furnished to the supplier within 45 days of the examination.
What is a Medicare site visit?
One important step in Medicare provider enrollment is a site visit. The site visit verification process is a screening mechanism to prevent questionable providers – and suppliers – from enrolling in Medicare.Jan 16, 2018
What is a Medicare CMN form?
A certificate of medical necessity (CMN) is documentation from a doctor which Medicare requires before it will cover certain durable medical equipment (DME). The CMN states the patient's diagnosis, prognosis, reason for the equipment, and estimated duration of need.
What needs to be on a WOPD?
The prescription (order) for the DME must meet all requirements for a WOPD and include all of the items below: Beneficiary's name, Physician's Name. Date of the order and the start date, if start date is different from the date of the order.Aug 1, 2018
How long does it take to get CMS approval?
CMS is presently averaging between four and six months to provide a response. Failure to provide CMS with all the necessary information and documentation at the time of submission can result in a “development request” from CMS which can delay the approval process further.
How long does it take to become Medicare certified?
Most Medicare provider number applications are taking up to 12 calendar days to process from the date we get your application. Some applications may take longer if they need to be assessed by the Department of Health.Jan 25, 2022
What items require a CMN for Medicare?
A Certificate of Medical Necessity (CMN) or DME Information Form (DIF) is required to help document the medical necessity and other coverage criteria for selected durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) items.
What is a DME information form?
A DIF is completed and signed by the supplier. It does not require the cost, a narrative description of equipment or a physician's signature. For certain items or services billed to a DME MAC , the supplier must receive a signed CMN from the treating physician or a signed from the supplier.Jan 28, 2022
What is a CMS 1500 form used for?
The CMS-1500 form is the standard claim form used by a non-institutional provider or supplier to bill Medicare carriers and durable medical equipment regional carriers (DMERCs) when a provider qualifies for a waiver from the Administrative Simplification Compliance Act (ASCA) requirement for electronic submission of ...Dec 1, 2021
How do you write a DME script?
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 5 element order?
The 6407- required order is referred to as a five-element order (5EO). The 5EO must meet all of the requirements below: The 5EO must include all of the following elements: Beneficiary's name. Item of DME ordered - this may be general – e.g., "hospital bed"– or may be more specific.
Can nurse practitioners order DME in Texas?
The passage of Senate Bill 406 in 2013 clarified that it is necessary to have prescriptive authority to order these devices and that APRNs and PAs may order or prescribe this equipment provided all requirements for delegation of prescriptive authority are met.May 27, 2014
General Information
CPT codes, descriptions and other data only are copyright 2021 American Medical Association. All Rights Reserved. Applicable FARS/HHSARS apply.
Article Guidance
Many errors reported in Medicare audits are due to claims submitted with incomplete or missing requisite documentation.
Bill Type Codes
Contractors may specify Bill Types to help providers identify those Bill Types typically used to report this service. Absence of a Bill Type does not guarantee that the article does not apply to that Bill Type.
Revenue Codes
Contractors may specify Revenue Codes to help providers identify those Revenue Codes typically used to report this service. In most instances Revenue Codes are purely advisory. Unless specified in the article, services reported under other Revenue Codes are equally subject to this coverage determination.
What is a standardized DMEPOS order?
Standardized DMEPOS Written Order/Prescription. Any Medicare provider or supplier that writes DMEPOS orders or prescriptions will now use a standard set of elements that will be applicable to all DMEPOS items. The treating practitioner must submit the complete written order to the supplier prior to submitting a claim for Medicare payment.
Who maintains the written order/prescription?
A supplier must maintain the written order/prescription and the supporting documentation provided by the treating practitioner and make them available to CMS and its agents upon request. CMS may suspend the face-to-face encounter and written order prior to delivery requirements generally, or for a particular item or items, ...
When was CMS 1713 finalized?
Final Rule CMS-1713: The rule, finalized in 2019, streamlines the requirements for ordering DMEPOS items, and develops a new list of DMEPOS items potentially subject to a face-to-face encounter, written orders prior to delivery, and/or prior authorization requirements.
Can CMS suspend a face to face meeting?
CMS may suspend the face-to-face encounter and written order prior to delivery requirements generally, or for a particular item or items, at any time and without creating a new rule, except for those items included on the Master List due to statutory mandate.
Do PMDs require face to face encounter?
Some items (such as PMDs) have statutorily imposed requirements. For items that do not have statutory requirements, a face-to-face encounter and written order is required only if the item is selected from the Master List and placed on the Required Face-to-Face and Written Order Prior to Delivery List. Items selected for the list will be published ...
Documentation Checklists
View documentation checklists created to help suppliers ensure all applicable documentation is readily available as part of Medicare claims payment and processing activities.
Standard Documentation Checklists
General Documentation Requirements apply to all DMEPOS categories. These checklists include the documentation required for payment and retention of that payment in the event of a review by entities looking at documentation today and in the future.
What is Medicare approved amount?
Medicare-Approved Amount. In Original Medicare, this is the amount a doctor or supplier that accepts assignment can be paid. It may be less than the actual amount a doctor or supplier charges. Medicare pays part of this amount and you’re responsible for the difference. , and the Part B.
What is Medicare assignment?
assignment. An agreement by your doctor, provider, or supplier to be paid directly by Medicare, to accept the payment amount Medicare approves for the service, and not to bill you for any more than the Medicare deductible and coinsurance. you pay 20% of the. Medicare-Approved Amount.
What percentage of Medicare payment does a supplier pay for assignment?
If your supplier accepts Assignment you pay 20% of the Medicare-approved amount, and the Part B Deductible applies. Medicare pays for different kinds of DME in different ways. Depending on the type of equipment:
What happens if you live in an area that's been declared a disaster or emergency?
If you live in an area that's been declared a disaster or emergency, the usual rules for your medical care may change for a short time. Learn more about how to replace lost or damaged equipment in a disaster or emergency .
Does Medicare cover DME equipment?
You may be able to choose whether to rent or buy the equipment. Medicare will only cover your DME if your doctors and DME suppliers are enrolled in Medicare. Doctors and suppliers have to meet strict standards to enroll and stay enrolled in Medicare.
What is MSM site verification?
MSM, or one of its subcontractors, will conduct a site verification and screening process according to Medicare guidelines to prevent questionable providers and suppliers from enrolling in the Medicare program.
How to contact MSM?
You may not copy or retain the ID or letter of authorization. You may contact MSM at any point if you have questions at 855-220-1074.
Standardized DMEPOS Written Order/Prescription
- Any Medicare provider or supplier that writes DMEPOS orders or prescriptions will now use a standard set of elements that will be applicable to all DMEPOS items. 1. Beneficiary name or Medicare Beneficiary Identifier (MBI) Number 2. Description of the item 3. Quantity, if applicable 4. Treating practitioner name or National Provider Identifier (NPI...
Consolidated DMEPOS Lists
- The Master List (PDF) is a library of all DMEPOS items posing vulnerabilities to the Trust Fund that may require providers/suppliers to comply with additional conditions related to payment requirements. From this list, items may be selected for one or both of the Required Lists: 1. The Required Face-to-Face Encounter and Written Order Prior to Delivery List 2. The Required Prior A…
Required Face-To-Face Encounter and Written Order Prior to Delivery List
- Review contractors assess compliance with the face-to-face encounter and written order prior to delivery requirements. Some items (such as PMDs) have statutorily imposed requirements. For items that do not have statutory requirements, a face-to-face encounter and written order is required only if the item is selected from the Master List and placed on the Required Face-to-Fac…
Written Order Prior to Delivery (WOPD) Requirements
- For items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, a complete order is required prior to the item’s delivery. (For all other DMEPOS items, the order is required prior to claim submission.) The Required Face-to-Face Encounter and Written Order Prior to Delivery List is currently under development and will be announced to the public with a 60-da…
Face-To-Face Encounter Requirements Applicable to Certain DMEPOS Items
- For all items requiring a face-to-face encounter, a practitioner visit is required within six months preceding the order. Note: face-to-face encounters for PMDs were previously required within 45 d...
- The encounter must be used to gather subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
- For all items requiring a face-to-face encounter, a practitioner visit is required within six months preceding the order. Note: face-to-face encounters for PMDs were previously required within 45 d...
- The encounter must be used to gather subjective and objective information associated with diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered.
- The face-to-face encounter must be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, trea...
- If the encounter is performed via telehealth, the requirements for telehealth services and payment for telehealth servicesmust be met.
Learn More
- DMEPOS Written Order, Face-to-Face Encounter, and/or Prior Authorization Requirements (PDF): Learn more about the standard elements for a DMEPOS order and items potentially subject to face-to-face encounter and written order prior to delivery and/or prior authorization requirements. Final Rule CMS-1713: The rule, finalized in 2019, streamlines the requirements for ordering DME…