Tips for getting Positive Airway Therapy claims paid
by Kelly J. Riley

Getting Positive Airway Therapy claims paid by Medicare continues to be a daunting task requiring too much time. Recently CGS—the DME MAC for Region C—published a “Positive Airway Pressure Devices Denial Help Aid” containing 12 categories on payment denial. Within those are 42 potential errors for patients who are beginning therapy, and an additional three for replacement equipment issues.

The 11 elements related to beginning patients on therapy, and their respective number of subcategories, are as follows: certificate of medical necessity (CMN, one); compliance (six); continued use and continued medical need (one); face-to-face evaluation (three); medical records (two); physician order/preliminary dispensing order (one); physician order/detailed written order (DWO, 10); proof of delivery (three); refill requirements (seven); sleep study (seven); and training (one).

The category with the most subcategories is the “detailed written order” from the prescriber. According to CMS, the prescriber may include doctors and mid-level practitioners such as advanced registered nurse practitioners (ARNPs) and physician assistants (PAs) as allowed by state law. When faced with an additional documentation request (ADR), many HMEs submit a “dispensing order,” not a DWO. There is a difference. The dispensing order—often called a preliminary order by the DME MACs—can be based on a written, fax or verbal order from the treating physician and suppliers must maintain written documentation of the order. The dispensing order must include a description of the item, the beneficiary and prescriber name, order and start date and the physician’s or supplier’s signature if it was a verbal order. This is achieved by completing an intake document. This process is then followed by a DWO that contains all the elements from the dispensing order plus the length of need for the item and the prescriber’s signature and date (entered by the prescriber). The 10 subcategories listed under DWO, as well as some operational tips, are as follows:

1) A copy of the DWO was not received—make sure it is the DWO that is being submitted and not the dispensing order.

2) The physician’s signature on the DWO is missing, therefore the identity and credentials of the person writing the order cannot be authenticated—the Program Integrity Manual (PIM) states that providers (prescribers) ordering items must be identifiable as part of the authentication process.

3) The physician signature on the DWO is illegible and on signature log or attestation statement submitted—again, this represents an authentication issue.

4) The physician did not personally date signature on the DWO—as stated in the PIM Section 5.2.3: “Someone other than the physician may complete the detailed description of the item. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement.”

5) DWO is invalid due to use of a signature and/or date stamp—from the PIM, handwriting is okay, as is an electronic signature, but no stamps.

6) DWO is missing one or more of the required elements—see previous paragraph.

7) DWO has changes that were not initialed and dated by the ordering physician—see previous paragraph.

8) Claim was submitted before the DWO was received by the supplier—PIM chapter 5, section 5.2.3, states: “Suppliers must have a detailed written order prior to submitting a claim. If the supplier does not have a faxed, photocopied, electronic or pen and ink signed detailed written order in their records before they submit a claim to Medicare (i.e., if there is no order or only a dispensing order), the claim will be denied.”

9) The DWO is unreadable due to illegible handwriting/poor copy—this goes back to the ability of CMS to authenticate the record. It’s the supplier’s responsibility to assure that all documentation requirements are met and legible copies are available.

10) The order is not a valid detailed written order because it is a blanket order or lacks sufficient detail to show that the item(s) the supplier delivered was the item(s) the physician actually ordered—if using a preprinted form, be sure all items are listed by HCPCS code and the physician has signed the order.