If you are a Medicare Part B provider, then you know how cumbersome a Medicare Part B audit can be. For most Medicare Part B audits, a pharmacy would be required to provide a valid Standard Written Order (SWO), medical records to support the diagnosis and continued need of the item, proof of delivery, and proof of refill request if mailing or delivering supplies.
This article is going to focus on the SWO. In January of 2020, CMS finalized Rule 1713 which created a unified order for all DMEPOS items. While this new SWO was designed to reduce the burden on both suppliers and providers, audit results would prove otherwise. The required elements of an SWO are:
- Beneficiaries name OR Medicare Beneficiary Identifier (MBI)
- The order date – this cannot be stamped
- A detailed description of the items ordered
- The quantity to be dispensed
- Treating practitioner’s name OR NPI
- Treating practitioner’s signature – this cannot be stamped
Below are the three most common SWO discrepancies PAAS National® sees on audit results and our guidance to help prevent these discrepancies from occurring.
- SWO is not signed by the practitioner
- The intake/data entry technician can check to be sure the provider manually signed the order (some states allow electronic signatures on a faxed electronic prescription), it just cannot be a stamped signature
- **NEW Guidance** Corrections to an SWO when the pharmacy did not obtain the practitioner’s signature regarding those corrections
- The practitioner must sign and date any revisions to the SWO and must be completed prior to submitting the claim
- Always obtain the prescribers signature for any changes or additions to an SWO or ask the prescriber to send a new SWO with the missing or additional information
- Billing a claim when there are no authorized refills remaining
- While refills are not a required element on the SWO, if the practitioner writes for refills, they will be honored exactly as specified regardless of the quantity dispensed
- **NEW Guidance** Medicare allows the initial fill and as many times subsequently for the exact refills indicated on the prescription after which the prescription would be considered expired
- Example: A pharmacy receives an order for a 90 days’ supply, plus three refills (i.e., a full year’s worth of medication). If the pharmacy can only bill for one month at a time (Medicare requirement on most DMEPOS items), the pharmacy can only fill off this SWO for a total of 4 fills (likely 120 days), regardless of the total quantity written. Additional fills would be considered unauthorized refills and ineligible for reimbursement, despite standard pharmacy practice.
- If you receive a prescription written for 90 days’ supply at a time with refills, ask the prescriber to resend the SWO written for 30 days’ supply at a time plus an adjusted number of refills to avoid unauthorized refills on an expired SWO
- PAAS National® has been corresponding with DME MACs to express our displeasure regarding this non-standard practice of requiring a prescriber’s signature on a clinical notation as well as not allowing the total quantity prescribed to be dispensed (when the refills constrain the number of dispensings) on the SWO – we will continue to advocate for pharmacies accordingly
- Review the following Newsline articles for additional information:
- PAAS recommends pharmacies review their DME MAC website for revised bulletin articles, webinars on the new SWO, and other educational materials. Click here for standard documentation requirements for all claims submitted to DME MACs.
- DMEPOS Updated Refill Request and Affirmative Response Requirements - February 11, 2024
- 2024 Update: CMS Mandatory E-Prescribing Requirements for Controlled Substances – Final Rule - January 18, 2024
- PBM Prescription Validation Requests Rose 123% in 2023 – What You Need to Know - January 12, 2024