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.