Standard Documentation Language for Local Coverage Determinations
Many errors reported in DME MAC MR Reviews and CERT Audits arise from problems associated with submitted documentation. Discussions about documentation issues commonly focus on inadequate medical record information not created by the billing supplier. However, in addition to medical record information related errors, numerous errors are identified due to noncompliance with non-medical record documents. These errors can often be avoided by the supplier. LCDs are being revised to include more detailed information about documentation requirements.
An expanded and standardized DOCUMENTATION REQUIREMENTS section has been developed. It is written in a modular format to allow each policy to contain information relevant to that policy while not including material that does not apply. This revised section includes considerable detailed information about existing Medicare requirements that has historically been found in the DME MAC Supplier Manual or in CMS interpretive manuals. Suppliers are strongly encouraged to review this material and use it to ensure that the records created will meet the standards required to justify payment for the DMEPOS item(s) provided.