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NEW CMSs, DIFs RAISE QUESTIONS OF MEDICAL NECESSITY

Published on Mon Jan 23, 2006

Physician education is the key to good documentation.

Documentation of medical necessity remains a thorny issue for DME suppliers, and one recent procedural update doesn't offer much help.

An updated transmittal from the Centers for Medicare & Medicaid Services reminds suppliers that new CMNs and DIFs for durable medical equipment are fast approaching, but it doesn't provide needed answers as to how much documentation is enough, say industry experts.

Many updates and changes were announced in CMS' Feb. 10 transmittal on certificates of medical necessity and DME Medicare Administrative Contractor information forms (see Eli's HCW, Vol. XV, No. 7). But one section left unchanged raises the most questions.

Section 5.7 still reads "However, neither a physician's order nor a CMN nor a DIF nor a supplier prepared statement nor a physician attestation by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier."

This language doesn't sit well with some industry experts. "That statement is still contrary to the prevailing legal opinion, and [documentation of medical necessity] is a very significant ongoing issue for suppliers," attorney Seth Lundy of Fulbright & Jaworski's Washington office tells Eli.

Lundy points out that the 2005 final ruling in a case filed by Redding, CA DME supplier Maximum Comfort Inc. confirmed the CMN should constitute sufficient proof for Medicare reimbursement (see Eli's HCW, Vol. XIV, No. 45).

Not knowing what information or documentation will prove medical necessity puts suppliers in an uncomfortable position, says Lundy. "It's kind of like an old Supreme Court opinion on pornography--they know it when they see it," he says.

Another problem: Some suppliers with concerns about proving medical necessity point to difficulties in getting supporting documentation from physicians. "Many physicians don't seem to understand why they have to provide more information than they originally provided in the CMN," says Sharon Hildebrandt, executive director of the Washington-based National Coalition for Assistive & Rehab Technology.

CMS has done a questionable job of updating physicians, says Hildebrandt. Putting updates on its Web site and publishing Medlearn Matters articles aren't the most effective ways to reach physicians, she points out. As a result, many suppliers must take physician education into their own hands, she says.

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