Submitting Documentation to Medicare

Introduction

The following are abstracts from the educational presentation “DME MAC CERT Education Task Force: Collaborating for Medicare Program Improvement” dated January 2010. They describe the Comprehensive Error Rate Testing (CERT) auditing system requirements on DME Suppliers, and provide an excellent guide as to what documentation should be submitted with a Medicare claim and appeal to maximize chances for a favorable determination. My comments as to applicability to the Medicare claim and appeal of lymphedema compression garment denials are shown between **asterisks**.

Applicable Rules and Regulations

Indications and Limitations of Coverage and/or Medical Necessity:

For any item to be covered by Medicare, it must:

1. be eligible for a defined Medicare benefit category
2. be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and
3. meet all other applicable Medicare statutory and regulatory requirements.

**

1. Compression bandages and garments when they are used in the compression therapy of lymphedema have been shown by many Administrative Law Judges to meet the definition of “prosthetic devices” benefit category.
2. They have been shown to be “reasonable and necessary” in the treatment of diagnosed lymphedema, and by the prescribing physician.
3. And they meet all APPLICABLE Medicare statutory and regulatory requirements. They are rejected because they do not meet the coverage criteria found in NON-APPLICABLE local coverage determinations (LCDs) for other benefit categories (e.g. durable medical equipment, surgical dressings, splints and braces). **

Applicable Rules and Regulations

Documentation Requirements:

Section 1833(e) of the Social Security Act precludes payment to any provider of services unless "there has been furnished such information as may be necessary in order to determine the amounts due such provider".

** It is essential that a PAID invoice showing the Supplier's name and address, Supplier's and referring physician's National Provider Identifier (NPI), the full description and cost of each bandage system or garment, and the indication of its use in the treatment of diagnosed lymphedema. The Supplier must be Medicare-Enrolled and registered with the National Supplier Clearinghouse (NSC). **

Responding to CERT Requests

What medical records are necessary?

Ask yourself these questions:

• Does the item fit a Medicare benefit category?
• Is the item statutorily excluded from coverage?
• Is the item medically reasonable and necessary?
• Is there documentation to support the item was provided?
• Is there documentation to support frequency/quantity?
• Is there documentation to support current medical need?
• Is the item coded and billed correctly?
• Do the medical records on hand support coverage requirements listed in any related LCD or NCD?

What medical records are necessary?

Ensure the medical records answer those questions by containing:

• Patient's diagnosis
• Duration of patient's condition
• Clinical course
• Nature and extent of functional limitation
• Prognosis
• Current need/use of the item
• Frequency and/or quantity prescribed
• Etc.

**An example of the application of the above to the errors common in the home treatment of another chronic medical condition, diabetes, may be illustrative of the requirements for lymphedema home treatment.**

Frequent Errors: Diabetic Supplies

• Physician order is incomplete or missing.
• No beneficiary test log or other justification for test frequency.
• No medical documentation to support reason the patient is testing above policy limits.
• No physician medical records to support the diagnosis.
• No documentation to show testing is as prescribed or beneficiary is not testing as prescribed (i.e. conflicting documentation).
• No legible physician identifier.

**In the above case substitute “wearing of compression garment” for “test or testing” **

Pre-submitted Questions

Question: “What key elements will the CERT contractors be addressing during a review?”

Answer: Documentation to support medical necessity and proof that the coverage criteria is met and appropriate code guidelines are followed.

**The crux of the problem is that the coverage criteria being applied are criteria for benefit categories not appropriate to the medical function of compression in the treatment of lymphedema, hence the garments are denied.**

Acknowledgement

Bob Weiss, LymphActivist

The above opinions are not to be taken as medical or legal advice. They are the opinions of an informed lay advocate. The commenter, Robert Weiss, is not a lawyer or a doctor, and the opinions stated above **between asterisks** do not reflect the current Medicare policies as interpreted by Medicare Contractors although they are supported by the majority of the U.S. Administrative Law Judges who have reviewed the legal arguments and have heard testimony of medical experts.

LymphNotes thanks Bob Weiss for his input on this complex and imporant topic.

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Category: Insurance and Medicare Updated: 2011-09-28