CMS requires that for Specified Covered Items, payment may only be made if a physician has communicated to the supplier a written order for the item before the delivery of the item. For many items of DME, a physician must document that a physician, a physician as-sistant (PA), a nurse practitioner (NP), or a clinical nurse specialist (CNS) has had a face-to-face encounter with the beneficiary pursuant to that order. The encounter must occur during the six months prior to the written order for each item. The patient’s medical record must con-tain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and must be signed by the ordering physician.
- Duration of patient’s condition
- Clinical course Prognosis
- Nature and extent of functional limitations
- Other Therapeutic interventions and results
Key Items to Address
- Why does the patient require the item?
- Do the physical examination find-ings support the need for the item?
- Signs and symptoms that indicate the need for the item.
- Diagnoses that are responsible for these signs and symptoms.
- Other diagnoses that may relate to the need for the item.
- The information must not be re-corded in vague and subjective terms.
- The information must provide ob-jective measures, tests or observa-tions.
- Each medical record is expected to be individualized to the unique patient.
- Impaired nutritional status
- Fecal or urinary incontinence
- Altered sensory perception
- Compromised circulatory status
In each case the medical record must document the severity of the condition sufficiently to dem-onstrate the medical necessity for the pressure reducing support surface.
Group 2 mattress overlay or mattress –
One of the following three criteria must be met and documented:
- The patient has multiple stage II pressure ulcers located on the trunk or pel-vis which have failed to improve over the past month, during which time the patient has been on a comprehensive ulcer treatment program including each of the following:
- Use of an appropriate group 1 support surface, and
- Regular assessment by a nurse, physician, or other licensed health care practitioner, and
- Appropriate turning and positioning, and
- Appropriate wound care, and
- Appropriate management of moisture/incontinence, and
- Nutritional assessment and intervention consistent with the overall plan of care.
- The patient has large or multiple stage-II or IV pressure ulcers on the trunk or pelvis
- The patient had a myocutaneous flap or skin graft for pressure ulcer on the trunk or pelvis within the past 60 days and has been on a group 2 or 3 support surface immediately prior to discharge from a hospital or nursing facility within the past 30 days