By Donna Youngblood, RN, BSN, CPC
If you are dispensing consumable/non consumable supplies or rented DME items are being used by patients, there must be information in each patient’s medical record to support that the item continues to remain reasonable and necessary. Issues may arise after you receive that original order with “99” refills with no further documentation on hand two years later. Even though you may have a valid order for dispensing, CMS wants to be sure that the item(s) continue to be needed by the patient. Documentation used to justify continued medical need must be timely for the DOS under review. Timely documentation is defined as an order or progress note in the preceding 12 months unless otherwise specified within an LCD or NCD. The following may support continued medical need:
- A recent order by the treating physician/practitioner for refills; or
- A recent change in prescription; or
- A properly completed CMN or DIF with an appropriate length of need specified; or
- Timely documentation in the patient’s medical record showing usage of the item
Suppliers should create a process of obtaining an annual order or progress note documenting the patient continues to use the DMEPOS in question. All information should be kept in the patient’s file in the event of an audit. This is a proactive approach so you are not scrambling when that audit letter arrives.