The appeals court reaffirmed the position previously expressed by the HHS Medicare Appeals Council that power wheelchairs and other DME furnished to beneficiaries and supported solely by a CMN, without supporting medical documentation, may be determined not medically reasonable and necessary and, therefore, not covered by Medicare.[15]. Medical Records Documentation Title. Id. It held that the Medicare program “may require, as a condition of reimbursement to an equipment supplier, information in addition to that provided by the certificate of medical necessity.”[13]. No fee schedules, basic unit, relative values or related listings are included in CPT. Clinical Documentation Required for Wounds. The sole responsibility for the software, including any CDT and other content contained therein, is with (insert name of applicable entity) or the CMS; and no endorsement by the ADA is intended or implied. The information in the medical records should include the patient’s diagnosis and other pertinent information, including duration of the condition, clinical course, prognosis, nature and extent of functional limitations, other therapeutic interventions and results, and past experience with related items. Visit our sister company Compliance Resource Center for custom tools and services, designed to meet your compliance program needs. The scope of this license is determined by the AMA, the copyright holder. Supra n. 11; MacKenzie Medical Supply Inc. v. Leavitt,506. Effective June 5, 2006, the following requirements were imposed: The regulations state that a supplier “may not dispense a PMD to a beneficiary until the PMD prescription and the supporting documentation have been received the physician or treating practitioner who performed the face-to-face examination of the beneficiary.”[17]. The Court found that section 1834(j)(2) of the Social Security Act, pertaining to CMNs, cannot be read as limiting the statutory requirement that no Medicare payment may be made for items and services not medically reasonable and necessary.[12]. Some of the Provider information contained on the Noridian Medicare web site is copyrighted by the American Medical Association, the American Dental Association, and/or the American Hospital Association. The U.S. Department of Justice, on behalf of CMS, then filed an appeal and asked the Court of Appeals for the Fourth Circuit to reverse the district court’s decision. You, your employees and agents are authorized to use CPT only as contained in the following authorized materials: Local Coverage Determinations (LCDs), training material, publications, and Medicare guidelines, internally within your organization within the United States for the sole use by yourself, employees and agents. Based on its review of a sample of claims, the carrier determined the supplier had failed to furnish documentation demonstrating that the claimed power wheelchairs were medically reasonable and necessary. Alexandria, VA 22315. Utilize Apria’s Refresh™ Fax Order Rx Form (ENT-4051), which includes the following: • Beneficiary’s name • Description or name of nutrients to be administered CMS Disclaimer The AMA warrants that due to the nature of CPT, it does not manipulate or process dates, therefore there is no Year 2000 issue with CPT. Therefore, you have no reasonable expectation of privacy. Occupational License(s) HME License(s) Oxygen Permit(s) / Retailer and Wholesalers License / Permit . Suppliers are reminded to review the Local Coverage Determination (LCD) and Policy Article for specific documentation guidelines. You acknowledge that the ADA holds all copyright, trademark and other rights in CDT. 2. Wheelchair Documentation Requirements for Medicare 1) RX – Wheelchair (standard or lightweight) Must include: wheelchair or light wt w/c, diagnosis, length of need,hgt and weight and signed /dated by doctor (no stamps allowed) 2) Suppliers also need to be cognizant of the current political environment regarding health care reform. LICENSE FOR USE OF "PHYSICIANS' CURRENT PROCEDURAL TERMINOLOGY", (CPT) 5, §5.7, Feb 3, 2008; effective March 1, 2008, available at www.cms.hhs.gov/manuals. These cookies will be stored in your browser only with your consent. The supplier was unsuccessful in appealing the overpayment determinations at the Medicare carrier level, so it requested review by an administrative law judge ALJ). BY CLICKING ABOVE ON THE LINK LABELED "I Accept", YOU HEREBY ACKNOWLEDGE THAT YOU HAVE READ, UNDERSTOOD AND AGREED TO ALL TERMS AND CONDITIONS SET FORTH IN THESE AGREEMENTS. Unauthorized or illegal use of the computer system is prohibited and subject to criminal and civil penalties. durable medical equipment (DME) supplier will need to: • Request “prior authorization” for certain types of power wheelchairs (listed on pages 3–4) • Send the required documents to Medicare along with the request You can submit the request yourself if you get the required documents from your doctor and DME … BEFORE: Physicians needed to include a separate statement about how much longer home health services would be needed as part of the home health recertification. The recent action by the U.S. Supreme Court, coupled with the OIG’s recent recommendations and CMS’ new “high dollar” DME review program, should highlight to suppliers the importance of securing and retaining documentation of medical necessity. It should be noted that without meeting the payer requirements, the claim will be denied. For DME to be covered by Medicare, the medical records must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items claimed.