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Linda Collins Blogger

Medical Record Documentation Requirements

Posted by Linda Collins | May 03, 2016

We all know the importance of obtaining physician corroborating documentation to support medical necessity of the product. We also know this can be a challenge. Many physicians are not familiar with the medical necessity documentation requirements and depend upon you, as the O&P expert, to provide details.

It is acceptable to use letters as a way to communicate with the physicians. It is not CMS's intent to restrict necessary communication between the supplier and the physician. CMS does not require nor regulate the cover letter. However, according to CMS, a supplier prepared statement or letter does NOT provide sufficient documentation of medical necessity, even though it is signed by the treating physician. There must be information in the patient's medical record that supports the medical necessity for the item.

For any DMEPOS item to be covered by Medicare, the patient's medical record must contain sufficient documentation of the patient's medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient's diagnosis and other pertinent information including, but not limited to, duration of the patient's condition, clinical course (worsening or improvement), prognosis, nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc.

Additional information about documentation requirements can be found in the "Medicare Program Integrity Manual" (Pub. 100-08), Chapter 3, Section 3.2.3.3,".

Look for additional details about using templates as documentation in an upcoming Össur R&R post. 

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If you have any questions for Össur’s Reimbursement Team or about Össur’s Reimbursement Services, please contact us at reimbursement411@ossur.com