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Printed Date: 9/22/2015
For any Durable Medical Equipment, Prosthetic, Orthotic and Supply (DMEPOS) item to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity for the type of equipment or supply, quantity and/or frequency of use or replacement, if applicable.
Medical documentation to support medical necessity should include pertinent and relevant information such as:
For selected claims, various auditing entities may request this information from the DME supplier. These DME suppliers are your partners in caring for your patients. When questions arise about Medicare’s coverage criteria for an item, reach out to them for verification. They will not receive payment from Medicare for the items that are ordered if you do not provide information from your medical records when it is requested. In addition, when thorough medical records cannot be obtained by the DME supplier an Advance Beneficiary Notice of Non-coverage (ABN) may be the only resolution which will result in your patients having to pay for the items out of pocket.
Jurisdiction A - CT, DE, MA, ME, MD, NH, NJ, NY, PA, RI, VT, Washington D.C.
Jurisdiction B - IL, IN, KY, MI, MN, OH, WI
Jurisdiction C - AL, AR, CO, FL, GA, LA, MS, NM, NC, OK, Puerto Rico, SC, TN, TX, USVI, VA, WV
Jurisdiction D - Am. Samoa, Guam, N. Mariana Is., AK, AZ, CA, HI, ID, IA, KS, MO, MT, NE, NV, ND, OR, SD, UT, WA, WY
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Last Updated: 04/13/2018