Balancing Act

Last year, the four durable medical equipment regional carriers issued supplier-manual updates requiring home medical equipment suppliers, in certain circumstances such as pre-and post-pay audits, to submit physician progress notes to substantiate medical necessity for a particular claim.

Then, in December, the Centers for Medicare and Medicaid Services, in its certificate of medical necessity submission to the White House's Office of Management and Budget, reported “suppliers and physicians will complete these [CMN] forms and as needed supply additional routine supporting documentation necessary to process claims.”

To put it plainly, CMS and the DMERCs have placed the burden on DME suppliers to provide to the DMERCs copies of physician progress notes to determine whether the medical necessity criteria were met for a particular claim.

The CMN should not be the sole determinant of whether a beneficiary meets the Medicare coverage criteria for a particular item. However, the government needs to balance its need for and use of additional documentation with the need for DME providers to be able to operate in a climate that does not impose on them inconsistent — or even impossible — burdens.

Suppliers should not be held liable financially when physicians' progress notes do not document medical necessity sufficiently for Medicare's purposes, especially when physicians have no financial or other incentive to completely document in their progress notes all information necessary to do so. This is particularly true when other physician-generated documentation exists that does document medical necessity.

The difficulty with relying solely on physician progress notes is that many physicians are not fully aware of all the details of the Medicare coverage policies for various DME, prosthetics, orthotics and supplies — nor should they be expected to be. Instead, the DMERCs should allow other physician-generated documents to prove medical necessity.

CMS and the DMERCs must provide DME suppliers with detailed information about the specific documentation that the DMERCs will consider sufficient to substantiate medical necessity.

In the spirit of striking a balance between the government's need to have sufficient documentation from the physician and the supplier's limited ability to educate physicians on the details of the Medicare policies for items, I suggest the following: