REIMBURSEMENT & CODINGNEWS for Jurisdiction D include modified language that notifies suppliers they have 45 calendar days from the date of the ADR request to submit their documentation . This is a change from the prior 30 day response time-frame previously utilized per CMS requirements . NAS staff will deny claims for which the requested documentation was not received by day 60 . During the transition to the new time-frame , suppliers are encouraged to review ADR letters to verify timeliness requirements for each claim .
The ADR letters generated by NAS contain specific fax numbers based on the department that needs the requested documentation . The NAS fax numbers for ADR receipts are similar and if the incorrect fax number is used for the documentation submission , this will delay claim processing . It is important that suppliers verify the fax number used matches the fax number on the ADR letter .
Standard Documentation Language for Local Coverage Determinations
Many errors reported in DME MAC MR Reviews and CERT Audits arise from problems associated with submitted documentation . Discussions about documentation issues commonly focus on inadequate medical record information not created by the billing supplier . However , in addition to medical record information related errors , numerous errors are identified due to noncompliance with non-medical record documents . These errors can often be avoided by the supplier . LCDs are being revised to include more detailed information about documentation requirements .
An expanded and standardized Documentation Requirements section has been developed . It is written in a modular format to allow each policy to contain information relevant to that policy while not including material that does not apply . This revised section includes considerable detailed information about existing Medicare requirements that has historically been found in the DME MAC Supplier Manual or in CMS interpretive manuals . Suppliers are strongly encouraged to review this material and use it to ensure that the records created will meet the standards required to justify payment for the DMEPOS item ( s ) provided .
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Referring-Ordering Education Article
As the Zone 5 Zone Program Integrity Contractor ( ZPIC ), AdvanceMed Corporation , LLC performs benefit integrity activities aimed to reduce fraud , waste , and abuse in the Medicare ( Part A , B , DME , Home Health and Hospice ) Program . Provider / supplier education is part of the ZPIC activities . In this educational article Zone 5 will highlight the responsibilities of the referring / ordering physician .
Title XVIII § 1833 ( q ) of the Social Security Act requires the referring / ordering physician information be submitted on a Medicare claim when the billing provider / supplier has received a referral or order for the referred / ordered service ( s ) or item . Section 1842 ( p )( 4 ) of the Act requires the referring / ordering physician provide documentation to the billing provider / supplier based on a referral / order :
In the case of an item or service defined in paragraph ( 3 ), ( 6 ), ( 8 ), or ( 9 ) of subsection 1861 ( s ) ordered by a physician or a practitioner specified in subsection ( b )( 18 )( C ), but furnished by another entity , if the Secretary ( or fiscal agent of the Secretary ) requires the entity furnishing the item or service to provide diagnostic or other medical information in order for payment to be made to the entity , the physician or practitioner shall provide that information to the entity at the time that the item or service is ordered by the physician or practitioner .
Pursuant to 42 Code of Federal Regulations ( CFR ) § 424.535 , a referring / ordering physician ’ s failure to provide the above required documentation that referring / ordering physician ’ s Medicare number may result in revocation . The revocation of enrollment and billing privileges in the Medicare program :
( a ) Reasons for revocation . CMS may revoke a currently enrolled provider or supplier ’ s Medicare billing privileges and any corresponding provider agreement or supplier agreement for the following reasons :
( 10 ) Failure to document or provide CMS access to documentation . ( i ) The provider or supplier ( as described in section 1866 ( j ) of the Act ) did not comply with the documentation or CMS access requirements specified in § 424.516 ( f ) of this subpart .
Regulation 42 CFR § 424.516 sets forth the types of documentation that are required to be provided by impacted provider / suppliers :
Additional provider and supplier requirements for enrolling and maintaining active enrollment status in the Medicare program . ( f ) Maintaining and providing access to documentation . ( 1 ) A provider or a supplier who furnishes covered ordered DMEPOS or referred home health , laboratory , imaging , or specialist services is required to maintain
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