DME Guide/Tips

(PDF Version)

Simple Tips to expedite a Durable Medical Equipment (DME) Order 

Provided by Confucius Pharmacy & Surgical Supplies - Nov , 2014

Recently, there seems to be many questions about prescribing Durable Medical Equipment (DME) and Supplies, e.g. how to write an accurate prescription, and the documents necessary for justification, etc.

In order to save time and efforts on paperwork and to enable your patients to successfully obtain the equipment you prescribe ASAP, here are some noteworthy points for reference:

1. Relevant Clinical Notes on Patient's Chart.

Always enter appropriate clinical notes on patient's chart relevant to the equipment you are prescribing. Medicare, Medicaid and their related insurances require copies of the "actual clinical notes" for audit purposes.

  1. Insurance companies are phasing out "Forms to fill out", clinical notes on patient's chart are proofs that physicians actually have examined patients for a condition relating to the equipment instead of just writing a prescription as per patient's request. Medicare has stated clearly that "Letter of Attestation- e.g. To whom it may concern letters are not acceptable as clinical notes. Other insurances are gradually following this guideline. Although some plans still use certain forms for certain items. The statements on these forms must be verified to correspond with the actual clinical notes.
  2. Clinical notes mean more than diagnosis codes or terms of diagnoses.
    More detailed narratives are necessary to describe why patient might need thequipment and how the equipment may help the patient. The narrative must describe: - Why the patient needs the DME?- How may the DME help the patient's conditions? - Why are other alternatives not sufficient, if appropriate?
  3. Record " XXXXX equipment is prescribed" just like you would when a new medication is prescribed on your clinical notes.
    e.g. clinical notes: Prescribe Back Support to reduce lower back pain due to compression fracture.
    (This states the diagnosis, the prescribed item and how it helps the patient's conditions - instead of just - Compression Fracture or Osteoarthritis and Nothing Else)
  4. These related clinical notes must be recorded on the date of the DME order or within 6 months prior to the order date.
    This proves that the doctor has indeed
    examined the patient for the indicated conditions before prescribing the DME.
    Sometimes physicians may not know the exact name and description of the equipment at the time of examination and prescribing. But as long the clinical notes and the doctor's intended care plan for the patient's conditions are in place, any later amendment to the original Rx will be acceptable.
    e.g. If we receive an Rx for "Back Brace" for compression fracture, after evaluating the patient, we may simply suggest the physician to confirm and sign a new and more precise Rx for a Thoracic Lumbar Sacral Orthosis (TLSO), or Lumbar Orthosis (LO), depending on fracture location and patient's height - an acceptable practice. 2 Confucius DME V112014

2. Prescriptions

In general, it is best to use a NY State issued serialized Rx blank to initiate your order.  State the items you are prescribing, the quantity , the diagnosis, the duration of usage if appropriate. Sign and date the Rx. The description can be typed, printed or stamped. Stamped signature and Stamped Date are not acceptable. E-Prescriptions are acceptable.

  1. Medicare requires a Detailed Written Order (DWO) with detailed description, components, etc on certain items. This DWO can be generated by the supplier for the doctor to sign, as a follow-up to an original Rx that might not be specific enough.
  2. Medicaid requires all DME orders to be written on the NYS Rx blank or on the pink Prior Authorization Form supplied by them.
  3. Medicaid also does not allow a DME Rx with a check list of items for the physicians to check off - deemed inappropriate.
  4. All Rxs must be signed and dated - stamped signature and date are not acceptable
  5. All Rxs must have NPI.

Additional Information:

1. In general, suppliers (e.g. Confucius Pharmacy & Surgical Supplies) must bill benefit plans in this order:

  1. Commercial Plan
  2. Medicare Part -B or Medicare Managed Plan (Medicare Advantage or Part C)
  3. Medicaid or Medicaid Managed Plan (Family Plus or Child health Plus)

Different Plans may require different "Forms" for authorization, but ALL PLANS Accept Clinical Notes from Patient's Chart and use them as basis for Audit. Depending on which plans we are billing, we must follow their criteria.

2. Obamacare plans (or Marketplace Health Plans - MHP) are considered Commercial Plans

3. Medicare (CMS) is always the initiator - coverage policies and criteria are being revised and implemented continuously under the new Affordable Care Act (ACA) to try to reduce costs. New coverage criteria such as Face-to-Face (F2F) are required on certain items, such as Glucose Monitor, Nebulizer, Wheelchair, Hospital Bed,etc. 

  1. The Physician must have a Face to Face Evaluation (F2F) with patient within 6 months prior to or on the date prescribing the DME .
    This report must be part of the clinical notes . There is No Forms for the doctor to sign or the doctor cannot write a "Letter of Attestation -To whom it may concern". This report - copy of the clinical notes - must be sent to supplier.
  2. The DME order or prescription is called Written Order Prior to Deliver (WOPD) and also must be sent to supplier. This (WOPD) can be generated by the supplier for the doctor to sign if the doctor is not familiar with all the detailed descriptions.
  3. The supplier can only dispense the product after receiving both the (F2F) and the (WOPD) .
    References website:
    1. (F2F) - Dear Doctor Letter from CMS
      http://www.medicarenhic.com/viewdoc.aspx?id=2581
    2. Products coverage criteria - from CMS
      http://www.medicarenhic.com/dme/mrlcdcurrent.aspx

Examples of some commonly prescribed DME products and acceptable narratives are listed for your reference only. The DME prescription must be precise and accurate.

(This is only a partial list of insurance covered items and generalized examples of usage criteria, not intended as substitute for physician's own examination and clinical notes. Please also refer to current Medicare/Medicaid manuals for details and complete rules and regulations)

 

 

DME Product Names

Contact us for items not listed

Examples of Narratives to be found in clinical notes.

Diagnoses codes only are deemed insufficient justification.

Anatomical Supports

Back Brace:

Lumbar Orthosis ; or Lumbar Sacral Orthosis

(Elastic Products generally considered Off the Shelf and not covered by insurance, even they do offer certain degree of support, a Rx containing words of elastic will not qualify for insurance coverage)

Thoracic Lumbar Sacral

Orthosis TLSO

Vest Type TLSO

Lower Back Pain

LSO prescribed: to reduce pain by restricting mobility of trunk or, to facilitate healing following a fall or injury (e.g. compression fracture) or, to support weak spinal muscle or, to support spinal deformity

Additional note:

Patient prescribed naproxene for pain and inflammation, but advised to wear LO during the day.

The selection of an LO, LSO or TLSO depends on the location of problem on spinal column and the patient's height.

Vest type TLSO may help some patients with kyphosis conditions

Ankle Brace, Gauntlet type

(A simple sleeve type is a non-covered item)

Ankle sprain from twisting or rolling- causing pain, inversion sprain of ankle ligament - causing pain
Need support to promote healing,

Knee Brace with Joints (or hinges)

With or without condylar pads

(A simple elastic brace without joints is a non-covered item)

Arthropathy

Wrist Brace

Wrist Brace with metal stay

Wrist Brace with thumb spica (with stiff support for thumb)

For Carpal Tunnel Syndrome

Wrist Sprain or Wrist and thumb sprains & strains

Arthropathy, De Quervain's tendinosis

Hernia Aid (Truss)

Patient has hernia and surgery is not preferable

Positioning Pillow

Cervical Supports

(neck collars- flexible or semi-rigid)

Neck Pain, Requiring adjustment in neck area to reduce pain

Neck pain, whiplash .

Used only temporarily to immobilize and support.

Surgical Support Stockings:

Gradient Compression stockings

Must specify:

-Knee high

-Thigh Length

-Waist Length (panty hose)

And compression

-Light 18-30mm Hg,

-Medium 30-40 mm Hg

-Heavy 40-50 mm Hg

Varicose Veins,

Excessive swelling from pregnancy - waist length (maternity panty hose)

Ambulatory Aids

Cane, Quad Cane

Walker

Walker with Wheels

Rollator (Wheeled Walker with seat)

Transporter (A chair with small wheels for caregiver to push patient in, not durable for use on streets)

Manual wheelchair (with bigger wheels for self-propelling if so desired, Standard size or Hemi-sized for patient with short stature)

Crutches (for patient who needs to keep weight off injured foot or leg temporarily)

e.g. If Osteoarthritis is the relevant diagnosis:

Patient has osteoarthritis and pain on both knees , has difficulty ambulating at home to perform activities of daily living, cannot use cane or walker because of pain in walking only a few steps. Home attendant or family are ready, willing and able to push patient around in wheelchair (it is OK for patient to use wheelchair outside the home, insurance coverage requires patient to have the need for wheelchair to use at home)

Shoes and Inserts

Orthopedic Shoes,( or Diabetes shoes for patient with DM)

Orthopedic shoes have high Toe boxes so there is room to fit a pair of inserts.

Custom Inserts (Custom Orthotics)

- Heat formed Inserts or

- Custom molded Inserts

Either one is prescribed for

For patient with diabetes . Custom molded Inserts provide better fit for patient with more pronounced deformities.

Patients with diabetes must have additional specific foot conditions to qualify( covered by Medicare & Medicaid Plans):

-previous amputation of parts of foot ,or

-history of previous foot ulceration, or

-history of pre-ulcerative calluses , or

-peripheral neuropathy with evidence of callus formation,

-foot deformity e.g. bunion, hammer toe, flat foot

-poor circulation - as examined and documented

Patients with no diabetes, only Medicaid /Medicaid sponsored types of plans will cover shoes and/or inserts when patient has no diabetes. Additional qualifying diagnoses include: Heel spur, plantar fasciitis, arthropathy .

Custom Inserts (Custom Orthotics) for children.

-Custom Molded Inserts

Molded to contour of feet, especially the Arch support.

-Custom UCBL

(Invented by University of California Biomechanics Lab) providing maximum support to correct flat feet, offering a stiffer support , especially suitable for younger children.

Custom Molded Inserts or Custom UCBL are covered by Most Insurance (e.g. Child Health Plus)

Children with problems resulting from congenital or acquired flat feet (Pes Planus) respond very well to custom orthotics that can easily be fitted with their athletic shoes, resulting in a less sedentary life style and better social interactions.

Many pediatricians prescribe Custom molded Inserts to children with flat feet every year to accommodate their growing feet.

Please contact us for evaluation and/or recommendations on the most suitable orthotics for children

Bathroom Safety & Personal

Shower chair

For patient to sit while showering, may be placed inside a bath tub or shower stall.

For: Arthritis patient, patient cannot stand up for any duration of time

Transfer Bench

To be placed over the side of bath tub so patient may slide in and out for transfer , e.g. arthritis

Bath tub Safety Rail

Rail to be clamped on side of bath tub

Shower Grab Bar

May be installed within shower stall or on outside wall

For patient to hold on for safety reasons

Raised Toilet Seat

For patient who has difficulty sitting down in too low a position on regular toilet - e.g. arthritis

Toilet Safety Rail (1 pair)

Rails can be attached on both side of toilet so patient can grab to support while getting up or sitting down

Bedside commode

For patient who has difficulty to move around to go to bathroom

Urinal / Bed Pans

To be used in bed

Adult diapers/brief

Adult incontinence

Underpads (chux)

To protect against bedwetting

Glucose Monitor

Test Strips:

Must specify frequency of usage: QD, BID, etc

To be tested once daily.( For Medicare - Once daily is the normal quantity allowed - To be tested 2-3 times daily if patient is insulin dependent )

(For Medicaid type of insurances: frequency of more than once daily is allowed even if patient is not insulin dependent)

e.g. Newly diagnosed patient

Patient newly diagnosed with T2DM, recommend diet and exercise , no medication. Prescribing glucose monitor and test strips to be tested daily for SMBG (Self-Monitoring of Blood Glucose), will review results with patient in 3 months.

e.g. Replacing an old and broken glucose monitor

Pt being treated for T2DM for 3 yrs, SMBG as part of treatment plan. Old machine broke, needs replacement.

Glucose Monitor subject to F2F rule (see

For Gestation Diabetes: Test up to 4-5 times daily

Nebulizer

COPD patient , insufficient control with oral inhaler (MDI) because poor patient technique, prescribed ipratropium and albuterol nebulizing solutions to be used with nebulizer.

Automatic Blood Pressure

Monitor

-semi-automatic

Patient needs to pump bulb with hand

-fully automatic

-Cuff inflate automatically by pushing a button

(Semi-automatic must be dispensed if patient does not qualify)

Automatic Blood Pressure Monitor are covered

When patient has high blood pressure and self monitoring at home for record keeping is part of the doctor's treatment plan

Elderly patients often have difficulty inflating the bulb in semi-automatic monitor.

To justify the dispensing of Fully Automatic Monitor
Doctor must specify that patient has arthritis or other motor disorders involving upper extremities.

e.g Patient has weakness on wrist to inflate bulb.

Hospital Beds

A semi-electric hospital bed is the most user friendly type although there are a few types

It provides easy head & foot adjustment with an electric switch controlled by patient or caregiver.

Without the electric switch, an attendant needs to operate a crank at the end of the bed to adjust the head and foot.

The order must also include:

Mattress and Safety Bed Rails as accessories.

Coverage criteria for a hospital bed includes any of the following:

1. Patient has a medical condition that requires positioning of the body in ways not feasible for an ordinary bed, e.g. elevation of head/upper body for more than 30 degrees, or

2. Patient needs positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain

3. Patient needs the head of the bed to be elevated more than 30 degrees most of the time due to congestive heart failure, chronic pulmonary disease, or problems with aspiration, or

4. The beneficiary requires traction equipment, which can only be attached to a hospital bed.

For a patient to qualify for a semi-electric bed:

Patient needs to have a need for frequent changes in body position and/or has an immediate need for a change in body position, therefore requiring an electric switch.