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General Medicare Requirements

Avoid Claim Denial

Healthcare professionals can play a vital role in ensuring their Medicare patient’s therapy is covered, by keeping up to date on the current requirements, and providing all necessary documentation to the home healthcare provider in a timely manner.

Enforcement of Medicare’s documentation requirements has become more stringent, and it’s affecting both healthcare professionals and their patients. If a Medicare claim is denied, the patient may have to assume financial responsibility.

Apria is trying to assist everyone in understanding the new policies, in order to help patients get qualified claims covered by Medicare, rather than denied.

Working together, we can help patients get the equipment and services they need, while ensuring that Medicare coverage guidelines are met.

Medicare Face-to-Face Requirements

Oxygen, Positive Airway Pressure (PAP) devices and Negative Pressure Wound Therapy (NPWT), and some other items (such as nebulizers, beds, and wheelchairs) require documentation that the patient had an in-person, face-to-face examination by the treating practitioner prior to delivery of the applicable DME item(s).

Oxygen, Positive Airway Pressure (PAP) devices and Negative Pressure Wound Therapy (NPWT), and some other items (such as nebulizers, beds, and wheelchairs) require documentation that the patient had an in-person, face-to-face examination by the treating practitioner prior to delivery of the applicable DME item(s).

The record of the face-to-face encounter must document that the beneficiary was evaluated and/or treated for a condition that supports the item ordered.

A specific diagnosis is not required in the medical record/chart notes. However, for equipment for which an in-person, face-to-face examination is required, the documentation requirements are in addition to those documents required in the National Coverage Determination (NCD) or Local Coverage Determination (LCD).

Note

Medicare Local Coverage Determination (LCD) for some products may provide different time frames in which a face-to-face evaluation must be conducted.

If there is a variance between the timeframes defined in the Affordable Care Act and the LCD, the Local Coverage Determinations timeframe should always be used.

Medicare Written Order Prior to Delivery Requirements

A written order prior to delivery (WOPD) is required for certain durable medical equipment items. The date of the written order must not be prior to the date of the face-to-face encounter. The WOPD must include, at a minimum:

  • The patient’s name
  • Date of the order
  • The item of DME ordered
  • The prescribing practitioner’s National Provider Identifier (NPI)
  • The signature of the ordering practitioner
  • The signature date

For items provided on a periodic basis, the order must include:

  • Item(s) to be dispensed
  • Dosage or concentration, if applicable
  • Route of administration
  • Frequency of use
  • Quantity to be dispensed
  • Number of refills

Orders that only state “PRN” or “as needed” for replacement frequency, use or consumption, are not acceptable.

 

Note

Signature and date stamps are not allowed.

Medicare Update Regarding Face-to-Face Evaluations and Written Orders Prior to Delivery

In 2013, Medicare made additional changes to its documentation requirements that impacted many of the durable medical equipment items and services that Apria supplies. Specifically, while CMS has been requiring face-to-face evaluations and Written Orders Prior to Delivery (WOPDs) for a limited number of products for some time, the list of products requiring WOPDs was significantly expanded. The HCPCS codes subject to the new requirements are listed in Medicare’s MLN Matters Number: MM8304

Failure to provide documentation of the face-to-face evaluation will result in a “not medically necessary denial” and, as a result, an ABN would be required. Failure to provide a WOPD will result in the item or service not being covered by Medicare and, as a result, the patient would be responsible for payment.

Product  Face-to-Face Examination WOPD Other Medicare Requirements
Liquid Oxygen, Oxygen & Portable Tanks Exam must be conducted no more than 30 days prior to WOPD. New Requirement Additional clinical documents are still required for all Medicare patients. Please refer to the specific Local Coverage Determinations (LCDs)
Oxygen Concentrators & Home Transfill Systems Exam must be conducted no more than 30 days prior to the initial CMN.  
Positive Airway Pressure (PAP) devices/Respiratory Assist Devices (RADs) For new PAP patients initiating therapy, exam must be conducted prior to sleep study.* New Requirement
NPWT Exam must be conducted prior to WOPD.**  

Other DME

  • Hospital Beds
  • Nebulizers 
  • Wheelchairs
 Exam must be conducted no more than 6 months prior to WOPD. New Requirement

 

 

* The LCDs do not specify a time limit for a face-to-face evaluation for RADs; therefore, the face-to-face examination must be conducted no more than six (6) months prior to the written order.

** Medicare requires an evaluation to be performed for NPWT prior to the WOPD in addition to monthly wound assessments.

*** Requires a WOPD for new orders dated prior to May 25, 2017. New orders on or after May 25, 2017 do not require a WOPD.

Standard Written Order (SWO) Document Requirements

Download Standard Written Order (SWO) document requirements

Complete & Accurate Orders

In an attempt to eliminate some common errors in the ordering process, Apria has developed prescriptions for oxygen, sleep, non-invasive ventilation and negative pressure wound therapy that you are encouraged to use when ordering DME items. It's critical for Apria to obtain a valid order prior to claim submission.

We cannot overstate the importance of submitting a carefully completed order. Incomplete orders result in a high level of rework for the prescriber as well as for our internal customer service, billing and sales departments. It can also result in a delay in the delivery of needed items and services to your patients.

Our goal is to help make the order process more efficient and help reduce the overall cycle time of orders.

For your convenience, these fillable forms can be completed and faxed directly to Apria or used as a reference tool to make sure your electronic order forms contain all the documentation required for Medicare reimbursement.

SAVE TIME

  • Provide all the required documentation up front to help to minimize call-backs and follow-up requests.
  • Help to expedite patient delivery.

SAVE MONEY

  • Help ensure patient claims are covered and minimize their out-of-pocket expenses.
  • Save money by eliminating rework that is caused by incomplete or inaccurate orders.

Additional Medicare Resources

If you have more questions, visit our Resource Center where all of our Medicare resources and tools are located.

RESOURCE CENTER