Documentation requirements - to support coverage

In the next few slides, we will explore some specifics on documentation to support the care and treatment, as well as appropriate reimbursement, for claims.

For urological supplies, it is important to have some basic information clearly documented in the medical record, appropriately authenticated, and available for coverage submission. Basic requirements include a physician’s order. A standard written order (or SWO) is required and must be forwarded to a supplier of urological supplies before it can be billed. This order includes specific elements, such as the beneficiary’s name or Medicare Beneficiary Identifier, order date, description of the item, quantity to dispense, treating practitioner’s name or National Provider Identifier, and the treating practitioner’s signature.

Medical records should include a history of the condition and services and supplies received. In addition, documentation of the medical condition that justifies the medical necessity of supplies must be recorded. And keep in mind that these billed supplies may be used for diagnosis, direct care, and treatment as indicated for specific medical conditions.

The documentation required must meet the standards of practice for the local area where the service and supplies are provided. The United States is divided into four jurisdictions which are covered by Medicare Administrative Contractors (or MACs) and used for local coverage determinations. These MACs include Noridian Healthcare Solutions and CGS Administrators.

Documentation requirements - for urological supply claims

Medicare may cover up to 80% for external prosthetic items that are furnished by a supplier enrolled in Medicare. There are specific documentation requirements for these supplies. The administrative contractors for MACs in the local coverage determination jurisdictions have online checklists that can be used in assuring that documentation is complete and adequate.

All of the items listed on this slide are essential for the submission of a claim for coverage. Included are a prescription or order from the practitioner, medical record information that includes any continuing need and/or use of the supplies, correct coding, proof of delivery record (generally maintained by the supplier), and a Standard Written Order with all of the required components.

Criteria for Medicare coverage - for urological supplies

Medicare coverage for urological supplies requires specific documentation in the categories shown here. Included are permanent urinary retention or incontinence that is not corrected medically or surgically within three months. Supplies are not covered in cases that do not meet the definition of “permanent” in the guidelines, thus temporary conditions are not covered.

Related supplies are generally covered if they are necessary for proper use of the catheter or external device that meets the stated criteria.

Medical necessity is determined by the coverage. And depending on what supplies are needed the beneficiary or caregiver may perform the procedure. Written documentation will include a description of the item, the name of the beneficiary, the prescribing physician’s or practitioner’s name, and the date of the order. If the order is written, it will require the signature of the physician or practitioner. If the order is verbal, it will require the supplier’s signature. The SWO will include the beneficiary’s name, description of all items in the order, options available, accessories or additional features that may be separately billed or that may require an upgraded code. The item can be described or can be identified with a Healthcare Common Procedure Coding System (or HCPCS) code or code narrative. It can also be identified by a brand name and model number. Included should be the quantity to dispense, and the prescribing physician’s or practitioner’s signature and date. If the quantities or type of supplies change, a new order will be necessary.

Documentation for catheter type and supplies should include justifications. For straight-tip catheters, the medical record should show documentation of a permanent urinary incontinence (PUI) or permanent urinary retention (PUR).

If a specialty catheter is ordered, documentation is required for the need of an indwelling or silicone catheter rather than a straight Foley-type catheter. For a coudé-tip catheter, the medical record should document obstruction or other reasons that a straight-tip catheter cannot be used.

If a sterile kit is to be used, the documentation should include either a PUI or PUR along with two urinary tract infections within a 12-month period if non-sterile catheterization is used, or in cases of immunosuppression, pregnancy with spinal cord injury that causes neurogenic bladder, residence in a nursing facility, or radiologic evidence of vesico-urethral reflux.

Documentation is required for refill requests, delivery, and other items.