Self-Audit Series #14: DMEPOS Items

Medicare Part B/DMEPOS billing and documentation rules are VERY different from most of your pharmacy claims – if you don’t have a strong grasp of these differences, or a process for handling the documentation, then you are sure to experience significant problems.

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Documentation for DMEPOS items

Standard Written Order (SWO)

  • SWOs must include the following six elements:
    1. Beneficiary’s name or their Medicare Beneficiary Identifier (MBI)
    2. Date of the order must be present
    3. General description of the items – HCPCS code a HCPCS code narrative, or a brand name/model number
    4. Quantity to be dispensed
    5. Practitioner’s name or NPI
    6. Practitioner’s signature
  • Other important items to know:
    • Medicare accepts electronic, faxes and written orders. Telephone and transfer orders do NOT satisfy Medicare requirements
    • Must have SWO in your possession prior to billing claims
    • Not required to have a diagnosis code on the order; however, the correct diagnosis code is needed to appropriately bill the claim
    • As of January 2020, pharmacies may obtain and make note of verbal clarifications
  • See our January 2019 Newsline article Billing Medicare Part B – Nebulizer Drugs for requirements of a valid detailed writer order (DWO) if being audited on a claim with an order written prior to 2020

Proof of Refill Request (PORR)

  • Refill requests include the following four elements:
    1. Name of beneficiary (or representative) making the request
    2. Description of each item requested
    3. Date of refill request
    4. Quantity that beneficiary still has remaining
  • NOT required for items picked up at your pharmacy
  • PORR may not be obtained more than 14 days before exhaustion of current supply or delivered to the patient more than 10 days before exhaustion

Proof of Delivery (POD)

  • POD must include the following six elements:
    1. Beneficiary name
    2. Delivery address
    3. Detailed description of the item(s)
    4. Quantity delivered
    5. Date delivered
    6. Signature of beneficiary or representative
  • Important notes:
    • Date of delivery should match the date of service billed (there is no “return to stock” window)
    • Applies to all DMEPOS dispensing – even when picked up at pharmacy
    • Standard “signature logs” used for PBM audits generally do not satisfy requirements
    • Most common items missing on audit = delivery address, detailed description, quantity
    • Many pharmacies will add duplicate Prescription dispensing label to provide

Medical Records

  • In general, medical records should conform to the following:
    • Be created on or before the prescription order (SWO)
    • Support the underlying diagnosis or condition
    • Be signed by the treating practitioner
  • To prove “continued medical need” of ongoing supplies or rental items, medical records must be “timely” which is defined as a record in the preceding 12 months unless otherwise specified (e.g., high utilization of diabetic test strips requires medical records within previous 6 months)
  • Each DMEPOS product category requires different unique elements
  • Best practice would be to obtain records before dispensing items to patients

Billing for DMEPOS items

  • Medicare billing is based on HCPCS codes (not NDCs) and “units of service” (which varies by product)
  • Many pharmacies utilize software vendors such as OmniSYS and Change Healthcare to convert NCPDP D.0 claim information into an “837 file” that CMS claim processors recognize
  • Many DMEPOS items require “modifiers” to communicate various information
    • Example for diabetic test strip claims (A4253): ‘KS’ indicates that the patient is NOT using insulin, while ‘KX’ indicates that the patient IS using insulin
    • Example for claims billed during the public health emergency that do not meet all Medicare clinical indication requirements should be adding a ‘CR’ modifier to the claim if on or after 3/1/2020 and for the duration of the PHE – See March 2022 Newsline article Medicare not Enforcing Clinical Indications for Certain DMEPOS Categories during the PHE for more information on the ‘CR’ modifier

Dispensing for DMEPOS items

  • Must ensure that the signature date matches the date of service billed on the claim
  • Claim must be billed on the date picked up, or the date sent out for delivery
    • If the dates do not match and you identify this error on your own, you can resolve it proactively via a Reopening without having to request a formal appeal
    • If this error is discovered during an audit, pharmacies must appeal via a Redetermination. During the PHE, pharmacies are allowed to write a note to the medical reviewer asking them to adjust the date billed to match the date picked up

Be sure to utilize all the tools and resources available on your local DME MAC website to ensure you are compliant with Medicare’s billing and documentation rules.

  1. Durable Medical Equipment Medicare Administrative Contractor (DME MAC) websites
  2. Noridian Healthcare Solutions
  3. CGS® Administrators, LLC
  4. Supplier Manual
  5. Local Coverage Determinations (LCDs) that outline billing and documentation requirements that are specific for various items
  6. Documentation Checklists – these are created by the DME MACs to aid suppliers in adhering to rules
  7. Dear Physician Letters – letters written by physicians of the DME MACs that suppliers can provide to local prescribers to education them about documentation requirements
  8. Educational, on-demand webinars on a variety of topics

Jennifer Ottman, CPhT