Documentation and Orders for Respiratory Assistive Device

March 8th, 2018 - Medicare Learning Network
Categories:   Documentation Guidelines   Pulmonology   Medicare  
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The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines.

Providers must meet the following conditions:

  • The physician must document and communicate to the Durable Medical Equipment (DME) supplier that the physician/treating practitioner has had a face-to-face encounter with the beneficiary on the date of the written order or up to six months before the date of the written order.
  • During the face-to-face encounter, the physician/treating practitioner must conduct a needs assessment, evaluate, and/or treat the beneficiary for the medical condition that supports the need for each item ordered.
  • The face-to-face encounter must be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans, or other information as it may be appropriate). The physician must sign or co-sign the pertinent portion of the medical record indicating the occurrence of a face-to-face encounter for the beneficiary for the date of the face-to-face encounter when performed by a treating practitioner.
  • The date of the face-to-face examination must be on or before the date of the written order, no more than six months prior to the written order, and be on or before the date of delivery for the item(s) prescribed.

Orders are delivered via the following forms of communication:

  • A written order that is both signed and dated by the treating physician/treating practitioner prior to delivery. The written order is consistent with requirements in 42CFR 410.38(g)(4). This order must include:
    • Beneficiary’s name
    • Item of DME ordered
    • NPI of the prescribing physician/treating practitioner
    • Signature of the prescribing physician/treating practitioner
    • Date of the order
  • A supplier must maintain the written order and the supporting documentation provided by the physician/ treating practitioner and make them available to CMS upon request for seven years from the date of service consistent with 42 CFR 424.516(f)
  • Verbal or preliminary orders are not authorized

A new order is required in the following situations:

  • There is a change in the order for the accessory, supply, or drug
  • On a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy
  • When an item is replaced
  • When there is a change in the supplier

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