HCFA allows HHAs to use faxed CMNs, cover letters
HCFA allows HHAs to use faxed CMNs, cover letters
By MATTHEW HAY
HHBR Washington Correspondent
BALTIMORE The Health Care Financing Administration (HCFA; Baltimore) has offered guidance allowing durable medical equipment (DME) suppliers to use faxed certificates of medical necessity (CMN) in what will probably be the industry’s biggest regulatory victory this year. The program memorandum states that faxed CMNs may be used to initiate billing to the Medicare program as long as the original CMN is maintained.
In addition, HCFA instructed the durable medical equipment regional carriers (DMERC) to lift any restrictions that prohibit suppliers from communicating with physicians using cover letters. HCFA pointed out that cover letters are "not required by HCFA, nor regulated by HCFA" and said the DMERCs "should not take adverse action against suppliers that solely involve cover letters."
Confusion about the use of cover letters has swirled ever since the Region B DMERCs restricted their use last year.
HCFA outlined the documentation requirements for the DMERCs to follow and said claims that do not meet these requirements will be denied and/or an overpayment will be assessed.
According to HCFA, a written order must be sufficiently detailed, and it must include: the patient’s name, a description of the item (the description can be either a narrative or a brand name/model number), a physician’s signature, and all options or additional features. Options will be separately billed or will require an upgraded code. In addition, the date on the written order or the CMN should be the date that the physician has signed the written order and/or CMN. In addition, HCFA outlined these requirements:
• Suppliers must have a verbal, faxed, or original order in their records before they provide any item of durable medical equipment, prosthetics, orthotics, and supplies to a beneficiary.
• For items that are dispensed based on a verbal order, the written order must clearly specify the start date of the order. If the written order is for supplies that will be provided on a periodic basis, the written order should include appropriate information on the quantity used, frequency of change, and duration of need.
• A new written order and a new CMN are required when there is a change in equipment. For items that are recurring in nature, a new order and a new CMN is required if the beneficiary changes suppliers.
• A supplier must have a faxed or original signed order and a faxed or original CMN (when applicable) in its records before it can submit a claim for payment to Medicare. The DMERCs have the authority to request to see the original order or a CMN at any time. If the original order or CMN is not available either at the supplier’s or in the patient’s medical record maintained by the ordering physician, or if the faxed CMN has been altered, the DMERCs should consider the service not reasonable and necessary and initiate a denial or an overpayment action.
• Suppliers are also required to obtain a signed order from a physician before delivery of certain types of durable medical equipment. Items that require a written order prior to delivery are decubitus care items, seat-lift mechanisms, transcutaneous electric nerve stimulators (TENS), and power operated vehicles.
• If there is any change made to the CMN after the physician has completed Section B and signed the CMN, the physician must line through the correction, sign the correction in full, and date the change or the supplier may choose to have the physician complete a new CMN.
HCFA instructed the DMERCs to publish an article asking suppliers to remind physicians of their responsibility in completing and signing the CMN. "It is the physician’s responsibility to determine both the medical need for, and the utilization of, all healthcare services," HCFA stated. "The physician should ensure that information relating to the beneficiary’s condition is correct. The DMERCs should encourage suppliers to include language in their cover letters to remind physicians of their responsibilities."
The agency also addressed the DMERC’s authority to assess an overpayment or civil monetary penalty (CMP) when invalid CMNs are identified. "Failure to have a valid CMN on file or to submit a valid CMN to the DMERC makes the underlying claim improper because Medicare does not have sufficient information to determine whether the claim is reasonable and necessary," HCFA stated. The agency added that in cases where a DMERC determines that a supplier that has a pattern of improperly completing CMNs could slap that supplier with a CMP of up to $1,000.
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