Question:

What kind of documentation does Medicare require when physicians write requisitions or orders for respiratory-assistive devices (RADs)?

Answer:

This is a good question since the Centers for Medicare & Medicaid Services (CMS) recently published information about insufficient documentation for RADs. CMS gave the following guidelines to physicians and other non-physician practitioners:

  • Document and communicate to the durable medical equipment (DME) supplier that you had a face-to-face encounter with the beneficiary on or before the date of the written order. The encounter must be no more than six months prior to the written order, and be on or before the date of delivery for the item(s) prescribed.
  • Perform a needs assessment at the face-to-face encounter, and evaluate and/or treat the beneficiary for the medical condition that supports the need for each item ordered.
  • Document the face-to-face encounter in the pertinent portion of the medical record, and sign or co-sign the pertinent portion of the medical record indicating the date it occurred.

 

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