Here's a reminder from NGS of what they want in a DWO.
Jurisdiction B DME MAC Supplier Manual: Chapter 8
- Certificates of Medical Necessity
- Documentation in the Patient's Medical Record
- Request for Refill—Documentation
- Proof of Delivery Requirements
All items billed to Medicare require a prescription. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available to any Medicare contractor upon request.
Upon request by any Medicare contractor, the supplier must provide in a timely manner the detailed written order that they received from the physician in a format that the Medicare contractor can accept. Medicare Contractors will accept any of the following forms of an order:
- An original “pen and ink” document
- A photocopy
- A facsimile image, or
- An electronically maintained document
Note: An electronically maintained document is one that has been created, modified, and stored via electronic means, such as commercially available software packages and servers.
Items dispensed and/or billed that do not meet these prescription requirements and those listed below must be submitted with an EY modifier added to each affected HCPCS code.
Before dispensing any DMEPOS item to a beneficiary, the supplier must have an order from the treating physician. Except for items requiring a detailed written order prior to delivery, the “dispensing” order may be either a verbal order or a preliminary written order (original “pen and ink,” facsimile image, photocopy, or electronic). Suppliers must keep a record of the dispensing order on file and this documentation must be available to any Medicare contractor upon request.
The dispensing order must contain the following:
- Description of the item
- Beneficiary’s name
- Prescribing Physician’s name
- Date of the order and the start date, if the start date is different from the date of the order
- Physician signature (if a written order) or supplier signature (if verbal order)
For the date of the order, use the date the supplier is contacted by the physician (verbal) or the date entered by the physician (written dispensing order). The dispensing order does not need to be as comprehensive as the detailed written order, which is required before submitting a claim (see following section).
A detailed written order prior to delivery is required for the following:
- Pressure reducing support surfaces (group 1, 2, and 3), including mattress overlays, air-fluidized beds, and mattresses
- Seat lift mechanisms
- TENS units
- Power operated vehicles
- Power wheelchairs
- Wheelchair seating
- Negative pressure wound therapy pumps
The supplier must have a detailed written order for these items (see following section)—original “pen and ink,” facsimile image, photocopy, or electronic—which has been both signed and dated by the treating physician before dispensing the item. For these items, if the supplier does not have a detailed written order prior to delivery, it will be denied.
Detailed Written Orders
Before submitting a claim for any DMEPOS item to the DME MAC, the supplier must have a detailed written order (original “pen and ink,” facsimile image, photocopy, or electronic) which has been both signed and dated by the treating physician. This detailed written order is in addition to the dispensing order described above, unless the dispensing order meets all the requirements specified in this section.
The supplier may not submit a claim based only on a verbal order. If an item requires a CMN, and if section C of the CMN is sufficiently detailed, i.e., contains all the information described below, it may serve as the detailed written order.
The DIF used for PEN and external infusion pumps cannot serve as the detailed written order since they are not signed by the physician.
The detailed written order must contain all of the following:
- Beneficiary’s name
- Prescribing Physician’s name
- Date of the order and the start date of the order, if the start date is different from the date of the order
- Detailed description of the item(s)
- Physician signature and signature date
Items Provided on a Period Basis Including Drugs
For items provided on a periodic basis, including drugs, the detailed written order must also include:
- Item(s) to be dispensed
- Dosage or concentration, if applicable
- Route of administration
- Frequency of use
- Duration of infusion, if applicable
- Quantity to be dispensed
- Number of refills
Frequency of use information on orders must contain detailed instructions for use and specific amounts to be dispensed. Reimbursement shall be based on the specific utilization amount only. Orders that only state “PRN” or “as needed” utilization estimates for replacement frequency, use or consumption are not acceptable.
The detailed description of the item may be completed by someone other than the physician with exception of a power mobility device seven element written order. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement.
Signature and date stamps are not acceptable.
The detailed written order (required before submitting a claim) must be sufficiently detailed, including all options or additional features which will be separately billed or which will require an upgraded code. The description can be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number.
The diagnosis or ICD-9 code is not required on all written orders. Suppliers should refer to the specific local coverage determination for the item being ordered to determine if a diagnosis is required on the order. The diagnosis or ICD-9 code is required at the claim line level and must be specified to the most accurate fifth digit (ex. 250.00). Suppliers are expected to work with their physicians and physician staff to ensure the proper and most accurate diagnosis is billed. Documentation regarding the diagnosis should be found within the beneficiary’s comprehensive medical record and a diagnosis on the order alone will not substantiate the need for the item being ordered.
Requirements for New Orders
A routine refill prescription is not needed. A new order is required when:
- there is a change in the item(s), frequency of use, or amount prescribed
- on a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy
- an item is replaced
- there is a change in supplier
- there is a change in length of need or a previously established length of need expires
- by any state or federal laws
In cases where two or more suppliers merge, the resultant supplier should make all reasonable attempts to secure copies of all active orders from the supplier(s) purchased. This document should be kept on file by the resultant supplier and be available to the DME MAC on request.
For additional requirements for new orders please refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.2.4.
Special Rules for Nurse Practitioners and Clinical Nurse Specialists
A nurse practitioner or clinical nurse specialist may provide the dispensing order and sign the detailed written order if they satisfy all the following requirements:
- They are treating the beneficiary for the condition for which the item is needed
- They are practicing independently of a physician
- They bill Medicare for other covered services using their own NPI, and
- They are permitted to do all of the above in the state in which the services are rendered
Special Rules for Physician Assistants
A physician assistant may provide the dispensing order and may document and sign the detailed written order if they satisfy all the following requirements:
- They meet the definition of a physician assistant found in Section 1861(aa)(5) of the Social Security Act or Section 2156(A) of the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Section 5.5 and 5.6
- They are treating the beneficiary for the condition for which the item is needed
- They are practicing under the supervision of a doctor of medicine or doctor of osteopathy
- They have their own NPI, and
- They are permitted to perform services in accordance with state law
For additional requirements regarding nurse practitioners, clinical nurses, and physician assistants please refer to the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 5, Sections 5.5 and 5.6.
Medical necessity information (e.g., an ICD-9-CM) diagnosis code, narrative description of the patient’s condition, abilities, limitations, etc.) is not considered part of the order; although it may be entered on the same document as the order.
CMS published instructions to contractors on signature requirements. Those requirements are found in the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 18.104.22.168. (1 MB) They were effective for claims with dates of service on or after March 1, 2010.
These guidelines apply not only to claims reviewed by the DME MAC but also to claims reviewed by the CERT contractor, PSC, and rRAC.
For medical review purposes, Medicare requires that all orders and medical records that are used in the adjudication of claims be authenticated by the author. The method used must be a legible handwritten full signature, handwritten initials, or electronic signature. Stamped signatures are not acceptable.
Electronic Signature Protocols
Providers using electronic systems need to recognize that there is a potential for misuse or abuse with alternate signature methods. For example, providers need a system and software products that are protected against modification, etc., and should apply adequate administrative procedures that correspond to recognized standards and laws. The individual whose name is on the alternate signature method and the provider bear the responsibility for the authenticity of the information for which an attestation has been provided. Physicians are encouraged to check with their attorneys and malpractice insurers concerning the use of alternative signature methods. Electronic signature protocols must be available and provided upon request from any Medicare contractor.
If the signature is illegible on an order or medical record, the physician/practitioner may provide a signature log which includes the printed name of the author and the full signature or initials that appear on the document. Listing the credentials of the author is encouraged.
The following is an example of a signature log:
|Dr. John Smith||John Smith, M.D./JS||M.D.|
If the signature is missing on an order, the order will be disregarded and the claim will be denied.
If the signature is missing from the medical records, the physician/practitioner may provide an attestation to verify the entry. Physicians/practitioners should not add late signatures to the medical record (beyond the short delay that occurs during the transcription process), but instead may make use of the attestation process. In order to be considered valid for Medicare medical review purposes, an attestation statement must be signed and dated by the author of the medical record entry and must contain sufficient information to identify the beneficiary.
Should a physician/practitioner choose to submit an attestation statement, they may choose to use the following statement:
I _______________________ [full name of the physician/practitioner] ______________________, hereby attest that the medical record entry for _____________ [Date of Service] ______________ accurately reflects signatures notations that I made in my capacity as _______________________ [insert provider credentials, e.g., M.D.] _______________________ when I treated/diagnosed the above listed Medicare beneficiary. I do hereby attest that this information is true, accurate and complete to the best of my knowledge and I understand that any falsification, omission or concealment of material fact may subject me to administrative, civil or criminal liability.
Attestation statements will not be accepted where there is no associated medical record entry. Attestation statements from someone other than the author of the medical record entry in question are not acceptable (even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements).
When reviewing a file the reviewer will also take into consideration the following:
- If there are reasons for denial unrelated to signature requirements, the reviewer will not proceed to signature assessment.
- If the medical policy criteria cannot be met because a key piece of medical documentation contains a missing or illegible signature, the reviewer will proceed to the signature assessment.
If the signature is illegible, the reviewers will consider evidence in a signature log to determine the identity of the author of a medical record entry.
If the signature is missing from an order, the reviewers will disregard the order during the review of the claim.
If the signature is missing from any other medical documentation, the reviewer will accept a signature attestation from the author of the medical record entry.
- The reviewer will not consider an attestation statement if there is not an associated medical record entry.
- The reviewer will not consider an attestation statement from someone other than the author of the medical record entry in question—even in cases where two individuals are in the same group, one may not sign for the other in medical record entries or attestation statements.
If the reviewer determines that a claim is payable except for the signature requirements not being met, the reviewer will send a second development letter to the supplier and ask if they would like to obtain and submit a signature log or attestation statement from the physician/practitioner.
For more information, suppliers should also reference the CMS IOM Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 22.214.171.124. (1 MB) These signature requirements changes were effective for claims with dates of service on or after March 1, 2010.