In the month of February I traveled to four different cities for various association meetings, conferences or on-site client visits. During my travels I encountered suppliers that are all have or are currently being audited by one of many CMS contractors. Some suppliers indicated that the DME MACs’ prepayment review letters (ADRs) come to their office on a weekly basis. Others are experiencing postpay reviews from the ZPIC. These audits are considerably daunting and, when not handled appropriately, could result in 100% prepayment review of your claims or even revocation of your supplier number.
No matter the type of audit, one thing is certain. Preparing your files to be audited is your best defense. Although you, the supplier, has control over your own records, the documentation that is provided by the physician is heavily scrutinized by auditors to ensure medical necessity and coverage by Medicare is justified. Below I have provided answers to the common questions you encounter when requesting medical records from the beneficiary’s physician. Within the answers you will also see references from the IOM, Social Security Act and the Code of Federal Regulations for you to use when educating your physicians on the importance of their role in the documentation process.
Why do you need me to document?
For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable)…neither a physician’s order nor a CMN…nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN…or information on a supplier prepared statement or physician attestation (if applicable). [PIM Chapter 5, Section 5.7]
Says who?
Title XVIII Section 1842(p)(4): In the case of an item or service defined in paragraph (3), (6), (8), or (9) of subsection 1861(s) ordered by a physician or a practitioner specified in subsection (b)(18)(C), but furnished by another entity, if the Secretary (or fiscal agent of the Secretary) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity, the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.
What are the consequences to me if I don’t?
42 Code of Federal Regulations (CFR) § 424.535:
A referring/ordering physician’s failure to provide the above required documentation may result in the revocation of enrollment and billing privileges in the Medicare program:
- Reasons for revocation. CMS may revoke a currently enrolled provider or supplier’s Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons:
- Failure to document or provide CMS access to documentation. (i) The provider or supplier (as described in section 1866(j) of the Act) did not comply with the documentation or CMS access requirements specified in §424.516(f) of this subpart.