Thursday, June 23, 2011

Q. How can I ensure that I have proper documentation?

A. One of the most important issues a DME provider has to face is medical documentation. However, it is one issue that is frequently out of your control. With that said, there are a few steps that you can take to help ensure proper documentation exists for a service that you performed. 

Many providers feel they cannot provide a referral source with the requirements of the Medicare DMEPOS LCD. Providers often mistake this as a potential fraud or abuse issue. It is not. As a provider, it is your right to provide your referral source with the requirements for a specific product as it is written in the LCD. You are not allowed to direct the referral source to provide false information to make the product a covered item, or direct them on how to fill out CMNs with specific answers.

Educating a referral source on the policies of the products you provide is another way to start. DME providers with a large hospital-based referral source can meet with their discharge planners and do an in-service on their products. Additionally, work with your hospital's medical affairs office to arrange an in-service at one of their meetings. This is easier said than done, but you cannot just sit back and do nothing. 

Another way to accomplish training is to provide a handout for the referral source to inform them of what must be in the medical record. 

Do not take a "wait and see" approach. An audit can and will happen. The reimbursement you save will be worth any referral source you lose because "you are too strict."

Tom Walters is the president of Total Office Management. Reach him at 803-920-0606 or