To physicians, medical necessity means, “I am a doctor, and in my opinion, this patient needs this treatment.”
To Medicare, medical necessity means the care giving team has documented everything required to satisfy coverage requirements related to medical need per the Local Coverage Determination (LCD) for the product in question.
DME suppliers often have to go back to the treating practitioner and ask them to add more information to the medical record to bridge the gap between the competing definitions.
Below are four best practices to help DME suppliers collaborate with physicians to secure reimbursement and ensure patients get the care they need.
1. Addenda and Corrections Must be Signed and Dated.
In section 3.3.2.5 of the Program Integrity Manual (PIM), CMS explicitly prohibits auditors from considering undated or unsigned entries that are hand written into the margin of a medical record.
The DME MACs go a few steps further in the FAQ document “Documentation Requirements: Principles of Documentation Questions & Answers (Q&As).” In response to question 1, CGS states:
“[A]mendments, corrections, or addenda must:
- Clearly and permanently identify any amendment, correction, or delayed entry as such
- Clearly indicate the date and author of any amendment, correction, or delayed entry
- Clearly identify all original content, without deletion.”
That means, in addition to adding a title like “amendment” or “correction” to delineate any subsequent entry, authors should not remove or blackout any of the original language. Medical reviewers must be able to identify the original and the new text.
2. Delayed Entries Should be Added Within 48 Hours of the Original Visit
In the same Documentation Requirements FAQ, CGS notes that CMS has no specific timelines for corrections or other delayed entries to medical records.
While not directed at DME services, ancillary amendment guidelines for Part B providers offer useful specifics DME suppliers should consider. In “Documentation Guidelines for Amended Medical Records”, Part B contractor Noridian Healthcare Solutions suggests late entries should be:
- Added as soon as possible, and
- Only if the author has “total recall of the omitted information.”
Anecdotally, we have heard from medical reviewers they generally expect physicians to make corrections within 48 hours of the original visit to meet the “total recall” standard. Though subject to individual reviewer discretion, we believe the 48-hour rule will satisfy most.
3. Addenda Should Add Details to Foundational Information Already in the Chart Notes
In its Part B Documentation Guidelines document, Noridian indicates late entries should supply additional information omitted from the original entry. This goes to the question of foundation in the original entry. For example, it would be inappropriate for a doctor to come back and say, “Oh, by the way, the patient needs a nebulizer for wheezing” if the original notes only document mobility difficulties.
4. Treating Practitioners Should Incorporate Addenda Into the Original Chart Note
Treating practitioners will often draft standalone letters of medical need after the fact. Contractors, however, often exclude standalone documents from the medical record. To avoid this risk of exclusion, suppliers should suggest physicians incorporate addenda into the original chart note to ensure claim reviewers fully consider the update in adjudication and medical review decisions.
We hope these four guidelines foster improved communication between suppliers and referring physicians.