Medical Review Frequently Asked Questions (FAQs) – Winter 2012
Q1. According to CMS refill request requirements, suppliers must determine the quantity of supplies that the beneficiary has on hand at the time of the refill request. How should this information be documented? Should the supplier list the actual number of supplies on hand, e.g., “ has 14 lancets and 14 strips remaining”, or is acceptable to provide the information in terms of the number of days, e.g., “has 14 days of glucose monitoring supplies remaining”?
A1. Either of the above examples is an acceptable format for documenting the number of supplies on hand at the time of the refill request.
Q2. Does Medicare require that an electronic signature be accompanied by a statement indicating that the signature was applied electronically?
A2. CMS has not published formal regulations regarding electronic signatures. However, Medicare contractors strongly recommend that an electronic signature include a notation such as one of the following (not all-inclusive):
- Electronically signed by - Finalized by
- Authenticated by - Signed by
- Approved by - Validated by
- Completed by - Sealed by
Q3. Our pharmacy recently received an electronic prescription with the following electronic signature notation:
“Electronically signed and transmitted by Janet Smith, R.N., from ABC Practice Solutions per order of John Doe, M.D. at 04/04/2011 4:51:22PM”
Would the above qualify as a valid electronic signature under Medicare Part B?
A3. As stated above, CMS has not published regulations concerning electronic signatures per se. The signature requirements section (Chapter 3, §3.3.2.4) of the Medicare Program Integrity Manual (CMS IOM Manual 100-08,), does instruct DME MAC, CERT and ZPIC reviewers to accept valid e-prescribed orders for medications payable under Part B. However, this citation also points to PIM Chapter 5 for additional signature requirements concerning DMEPOS items. Chapter 5, §5.2.3 states:
Someone other than the physician may complete the detailed description of the item. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement.
Therefore, since the physician in the above example did not personally (electronically) sign and date the order, it would not be a valid detailed written order for the purpose of Medicare Part B payment.
Q4. When billing for enteral nutrition supplies, do the administration instructions on the detailed written order automatically cover related supplies, e.g. an IV pole for gravity or pump administration, or do these supplies have be separately itemized?
A4. Any equipment and supplies that will be separately billed (IV pole, supply kits, administration pump, etc.) must be individually listed on the detailed written order. Additionally, for supplies such as the administration kits that will be provided on a periodic basis, the written order should include information about the quantity used and frequency of refill .
Q5. We recently received a referral to provide oxygen to a patient and are unsure as to whether or not the arterial oxygen saturation results provided by the treating physician’s office meet the requirements for a valid qualifying test. The test was performed on room air during rest on 09/15/11 while the patient was in an inpatient hospital stay. The patient was discharged later that day to a Skilled Nursing Facility and went home from the SNF on 09/19/11. Under these circumstances, does the 09/15/11 test meet Medicare criteria?
A5. No it does not. In order to be a valid qualifying test, the oximetry reading must be taken within two days of discharge to the home. Therefore, since the patient was in a SNF until 09/19/11, the qualifying test could be performed no sooner than 09/17/11.
Q6. Can the Statement of Certifying Physician be a substitute for a detailed written order for therapeutic shoes for a person with diabetes?
A6. The Statement of Certifying Physician (SCP), as provided in the LCD, does not have all the required elements of a detailed written order (DWO). However, since this form is not an OMB-approved form, it is hypothetically possible for the form to be modified to also serve as a DWO. Two possible scenarios are provided below:
Scenario #1 – The Certifying Physician (who must be a M.D. or D.O.) and the Prescribing Physician ARE the same person – The SCP could serve as a valid DWO if it includes a list of all separately billed items and is completed, signed and dated by the physician.
Scenario #2 – The Certifying Physician (must be a M.D. or D.O.) and the Prescribing Physician (may be a M.D., D.O, D.P.M., F.N.P., or P.A. in this circumstance) ARE NOT the same person – The SCP could serve as a valid DWO if all separately billed items are listed on the form, the statement is completed, signed and dated by the Certifying Physician and is also signed and dated by the Prescribing Physician.Q7. We have been asked to provide CPAP equipment for a patient who had a face-to-face evaluation and a sleep test in early 2008. The patient however never tried CPAP. Now he is going to a new physician and that physician has ordered CPAP therapy based on the sleep test from 2008. Are the 2008 evaluation and 2008 sleep test sufficient to meet the documentation requirements in the PAP LCD or does the patient have to start over again with a new face-to-face exam and a new sleep test?
A7. In the situation described above, the patient should have a new face-to-face examination and a repeat sleep test before CPAP therapy is initiated. It is true that Medicare does not have an “official” time limit relative to the acceptable age of a sleep test. However when testing is performed, good medical practice standards dictate that action be taken promptly on any abnormal result. Additionally, many medical conditions change over time and the test results may not be an accurate reflection of the patient’s clinical condition after the passage of too much time. Accordingly, when records get past 3-6 months of age, medical review staff looks for some clear explanation as to the reason for the delay. Absent a clear, compelling explanation, older test results would be deemed as not sufficient to justify payment.
