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:

CMS should acknowledge that physicians commonly do not keep in their progress notes consistent and complete information regarding all the Medicare medical policy criteria that would qualify beneficiaries for particular items.

Just because a physician’s progress notes are incomplete does not mean that the beneficiary does not meet the medical necessity criteria.

CMS should provide the DMERCs with specific guidance about sufficient documentation to support medical necessity.

In practice, the DMERCs have inconsistent requirements and make subjective judgments that impose operational difficulties on multi-region suppliers.

CMS should instruct the DMERCs that physician-generated documents beyond the progress notes should be treated as if that documentation were in the physician progress notes.

The key is that the physician completed this other documentation, although it may not technically and physically be part of the physician progress notes.

CMS and the DMERCs should accept, as a statement of the patient’s actual medical condition, a physician-prepared letter of medical necessity or other documentation that is specific to a patient and explains why the patient requires a particular item, consistent with the Medicare coverage policy.

In addition, the DMERCs should accord the same weight to this physician documentation as they do to physician progress notes.

When a physician has limited patient information in the progress notes related to his or her prescription for a particular DME item, the DMERC should rely upon the more detailed evaluation of another health care professional.

For some DMEPOS items, it may be appropriate for a licensed health care professional other than the physician, such as a physical or occupational therapist, to assess the beneficiary and document those findings. Often, physicians rely on other health care professionals to evaluate patients and make judgments about the patients’ conditions and their need for certain items and services.

While, in theory, I do not disagree with the idea of relying on physician progress notes to determine whether medical necessity is met, the government needs to understand the realities of the DME marketplace.

The government must strike a balance between its need to determine medical necessity and the need to protect DME suppliers from unnecessary administrative burdens.

A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is an attorney with the law firm of Epstein, Becker & Green in Washington. Bachenheimer previously worked at the American Association for Homecare and the Health Industry Distributors Association. You can reach her by phone at 202/861-1825 or by e-mail at [email protected].