Wiki DME Medical Necessity Addendum

kle0204

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Patient was scheduled for surgery in the morning at an ambulatory surgical center. Provider realized that the patient did not have the correct knee brace so the clinic (we supply the DME, not the ASC) sent a referral to insurance and it was approved the same morning. Patient was discharged and went to the clinic to pick up the brace and was fitted by us that same afternoon.

The provider had mentioned "Patient will go into the brace" in his operative report. Because everything had occurred on the same DOS and the op report is his own, can he add an addendum to expand on the medical necessity of the knee brace on the ASC's op report, or does it have to be on a note within our clinic (i.e.: telephone encounter that indicates he had ordered the knee brace with an addendum that reflect a progress note (history, diagnosis, tx plan, medical necessity for the brace)?

Thank you!
 
I'm not aware of any rules that require any particular kinds of information to be located in a particular part of a patient's medical record. As long as the information is there and an auditor can easily find it if needed, that should be fine. I'd also recommend it be located somewhere that your medical records staff can also easily find it - in the event that there's a records request from a payer, you want to make sure the necessary information gets included.
 
I'm not aware of any rules that require any particular kinds of information to be located in a particular part of a patient's medical record. As long as the information is there and an auditor can easily find it if needed, that should be fine. I'd also recommend it be located somewhere that your medical records staff can also easily find it - in the event that there's a records request from a payer, you want to make sure the necessary information gets included.
Thank you so much!
 
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