DME Documentation Requirements for DME Providers

Heavily regulated and monitored, the durable medical equipment billing industry requires a significant amount of attention when submitting claims for payment from Medicare and other insurance carriers. To help DME providers stay current on claim documents, the Centers for Medicare and Medicaid Services (CMS) provide DME documentation requirements and guidelines. 

Comprehending and following these requirements will help to make sure submitted claims are accepted and paid on time. It also ensures that if you’re audited that all your claims meet the document requirements.  

What are the Documentation Guidelines for Durable Medical Equipment (DME)?

The primary purpose of the DME documentation requirements is to provide a paper trail that substantiates the person’s medically necessary reasons for needing the DME supplies. All supporting documents (prescriptions, clinical documentation, prior approval documents) must explain the necessary reasons for the DME supplies. The following information includes essential details regarding the documentation guidelines for DME. 

Take Advantage of Documentation Checklists Available 

Many DME documentation checklists are available to help your staff stay organized on the required documents and create a smooth billing process. Download this General Documentation Requirement Checklist from Noridian Healthcare Solutions for DME Jurisdiction D. 

This comprehensive checklist includes the documents you need to collect to ensure payment and retain that payment (in the event of an audit). There are various checklists available for other DMEPOS categories to help you collect all the required paperwork. View and download all DMEPOS Categories Documentation Checklists that apply to your business here. 

Claim Audits and DME Documentation Requirements 

The reason for Medicare DME audit reviews is to assure there is a medical necessity for supplying DME items to the patient. There are several types of audits, and each one looks at different areas of your business and claims submitted. 

Learn more about some of the most common Medicare DME audits below. 

• Comprehensive Error Rate Testing (CERT) Audit
• Medicare Administrative Contractors (MACs) Audits
• Recovery Audit Contractor (RAC)  
• Unified Program Integrity Contractors (UPIC) Audit

Be Audit Ready with a Document Management System

A document management system helps you prepare for an audit and organize and store all DME documentation paperwork. In addition, document management systems allow you to receive, track and manage patient records, which makes this a great system to have during an audit.

Physician’s DME Documentation Requirements 

Supplying Medicare and other insurance carriers with the physician’s documentation is vital to meeting the medical necessity requirements. As part of the DME documentation requirement, make sure to include the following information, from the physician, with all submitted claims. 

• Benefit and outcome of the patient using the DME items 
• Clinical and functional status of the patient to show medical necessity 
• Patient’s medical record 
• Licensed provider’s treatment plan

Patient’s Medical Record is Essential

One of the essential pieces to secure claim payment is the patient’s medical record. The patient’s medical history must support the additional documents which build the case for the DME provider showing the need for the DME supplies. 

For example, the patient record must show the reasons for the type of DME item, the amount needed, and how often it needs to be used or replaced. 

Medical DME Documentation Requirement 

Many resources are available to DME providers to help them understand how to provide accurate and supportive medical record documentation. When submitting claims, sometimes the required documentation isn’t required to be sent for the claim to be reimbursed. However, it’s important to note that those documents are still needed. In the event of an audit, you will be required to submit documentation to prove medical necessity, required supplier standards, and necessary documents according to the payer contracts.

This fact sheet on “Complying with Medical Record Documentation Requirements” will provide you with information on third-party documentation requests and common insufficient document errors.

This fact sheet was developed by the Medicare Learning Network (MLN), with CERT, Part A and Part B (A/B), and DME MAC Outreach & Education Task Forces. Visit the CMS CERT’s web page for more information on the CERT audits, improper payments reports, and CMS fact sheets. 

Avoiding Medical DME Documentation Errors

Taking the time to learn some of the common documentation errors other DME providers experience can help prepare you to avoid those problems. Here are some helpful tips for avoiding medical DME documentation errors. 

• Know about common coverage, coding, and billing errors using Provider Compliance Resources. 
• Check Healthcare Common Procedure Coding System (HCPCS) if any DME requires a written order before product delivery. 
• Include the physician’s National Provider Identifier (NPI) on all written orders.
• Make sure the ordering physician is actively enrolled in Medicare for the DME service date.

Common Questions Regarding the DME Documentation Requirements

Whether you have access to a surplus of information or are still learning the basics, here are some commonly asked questions regarding the DME documentation requirements. 

1. How long does a DME provider need to keep documentation?

 DME providers must maintain medical records and documents for seven years from the Date of Service (DOS).

2. What documentation is needed to bill Medicare DME?

The exact documentation needed will depend on the type of DME item, how frequently it’s used, the length of use, and the payer. Typically, you will need the patient’s medical records, which should include:

• History
• Physical examination
• Diagnostic tests
• Summary of findings
• Diagnoses
• Treatment plans

3. How to prepare my files to be audit ready? 

There are a few steps you can take to make sure your files are ready if you’re selected for an audit. 

• Review the claims process – Review the quality control and billing processes to look for missing pieces. 
• Evaluate denied claims – Study why claims were denied so you can learn about any potential gaps with the intake process. 
• Conduct your own audit – Examine your files and specifically look for missing pieces that lack the medically necessary component. 
• Learn from mistakes – Analyze all your findings and make the needed corrections to improve your billing process and be audit ready. 

Outsourcing Helps You Meet DME Documentation Requirements

Medbill is a DME billing company that is an expert within the DME billing industry. The Medbill team is current on the latest changes, industry guidelines, finding areas of improvement, and knows how to help you utilize current technology available. 

Outsourcing with the right company allows you to expand your company and free up your time to focus on other business areas. In addition, the Medbill team can educate and train your staff on faster, more efficient billing processes, which increases your claim approvals and becomes audit ready. 

Learn if Outsourcing is Right for You

As a full-service DME billing company, Medbill’s team can provide you with personalized support and help you stay up to date on industry guidelines and changes. Contact us to learn more about our DME billing services.