LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2011-05 CERT Reminders

Issue #5 May 2011

CERT Reminders
  • Although medical record information is not generally required to be submitted with a claim, it must be available upon request. We suggest that you consider gathering the relevant records at the time you provide the item to the beneficiary. This practice minimizes having to go back to the ordering physician at a later date.
    Please be aware that medical records are required to support the continued use of dispensed items.
  • There are various LCD-specific “Dear Physicianâ€? letters available on the NHIC, Corp. DME MAC A web site to facilitate suppliers’ request for medical records from the ordering/treating physician. The letters describe the types of medical records that the physician is responsible for documenting and supplying upon request. Please refer to the “Helpful Toolsâ€? section of this newsletter for more information.
  • An Order/Prescription must be signed and dated by the treating physician who ordered the item in question. Please reference: PIM 5.2.3: For orders, someone other than the physician may complete the detailed description of the item. However, the treating physician must review the detailed description and personally sign and date the order to indicate agreement.

NOTE: A nurse practitioner, clinical nurse specialist, or physician assistant may give the dispensing order and sign the written order. Please refer to Chapter 10 of the DME MAC A Supplier Manual for detailed requirements.

• When submitting a request for any level of appeal (Redeterminations, Reconsiderations, or Administrative Law Judge Hearing), please ensure to identify your case as a CERT claim.
o The Medicare DME Redetermination Request Form has an option to identify a CERT claim:

Overpayment Appeal: ï?¯ Yes If yes, who requested overpayment: ï?¯ Medical Review ï?¯ ZPIC/PSC ï?¯ CERT ï?¯ RAC

Please include the CID#. Contact Alina Jimenez for assistance with the CID# (contact information is in the “Helpful Tools� section of this newsletter).

• Ensure that the patient’s current Ordering/Referring/Treating Physician information is updated when submitting claims.

• Suppliers may dispense most DMEPOS items based on a verbal order (except for items requiring a written order prior to delivery). Suppliers must ensure to maintain written documentation of the verbal order, and this documentation must be available to the DME MAC upon request. For items that are dispensed based on
a verbal order, the supplier must then obtain a written order that meets the “Written Orders� requirement. Please refer to the Helpful Tools section for the Supplier Manual link for more information.

• Medicare requires that all documentation must be dated and must authenticate the author with a valid handwritten or electronically signed signature. Please refer to the DME MAC A Supplier Manual for guidance on signature requirements: http://www.medicarenhic.com/dme/suppmandownload.shtml

Issue #5
May 2011 Page 2 of 4 CERT and You
Issue #5 May 2011
• Clinical documentation submitted must support the medical necessity of the base item before payment may be considered for accessories and/or supplies. Please refer to the following Medical Review Bulletin: http://www.medicarenhic.com/dme/medical_review/mr_bulletins/mr_bulletin_current/SuppliesAccesories

• When billing for Surgical Dressings on the same claim as other DME items, such as Enteral Nutrition, documentation is required to support separate criteria for the Surgical Dressings. In many situations, the surgical dressings may be bundled into the other DME items they are being billed with.

CERT Review Examples
The following examples are CERT reviews which have been cited as errors. As you review these, consider what was missing that caused the error. We hope these will assist you in understanding the type of medical records being requested (please note the references following the examples):

A6212-A1 – Foam dressing, wound cover, sterile, pad size 16 sq. in. or less, with any size adhesive border, each
dressing  LCD L11471

  1. of units billed = 15
    Date of Service: 09/16/10
    • Received – Physician’s Order for a foam dressing to a surgical wound at the G-tube site to be changed qd; a wound evaluation by a nurse; several progress notes, most with unknown signatures which do not address wound care to the beneficiary’s G-tube site; and ulcer evaluation from 2009 from a pressure ulcer.
    • Missing – Clinical records from the treating provider supporting physician oversight of the beneficiary’s wound management including: Stage of the wound, type, location, size, amount of drainage, the reason for dressing use, wound treatments being provided, and the type of dressing changes being performed which includes the legible identification of the person performing and documenting the service; and a weekly evaluation which includes the type of each wound, location, size (length x width in cm.) and depth, amount of drainage, and any other relevant information which may be performed by nursing, wound management, or the physician.

A5500-KX – Fitting, custom preparation, and supply of off-the-shelf depth-inlay diabetic shoes  LCD L11535

  1. of units billed = 2
    A5512-KX – Multiple density inserts, prefabricated, each  LCD L11535
  2. of units billed = 6
    Date of Service: 06/24/10
    • Received – Statement of Certifying Physician which includes order for the shoes and inserts; delivery ticket that supports dispensing of 1 pair of shoes and inserts on 06/24/10; and a note advising that the supplier was unable to obtain records from the certifying physician.
    • Missing – Certifying physician’s clinical records that support physician oversight of beneficiary’s diabetic control and peripheral neuropathy with evidence of callus formation.

E0260-RR-KI – Hospital bed, semi-electric (head & foot adjustment), with any type side rails, with mattress  LCD L5049
Date of Service: 06/23/10
• Received – Supplier templated order dated 05/21/10; and referring physician’s notes dated 04/14/10 through 05/26/10 that support ambulating with a walker, lower extremity edema, no shortness of breath, and worsening dementia.
• Missing – Treating physician’s clinical records that support beneficiary’s medical condition(s) that require use of a hospital bed.

CERT and You B4035 – Enteral feeding supply kit; pump fed, per day  LCD L5041
  1. of units billed= 23
    B4154 – Enteral formula, nutritionally complete, for special metabolic needs, excludes inherited disease of metabolism, includes altered composition of proteins, fats, carbohydrates, vitamins and/or minerals, may include fiber, administered through an enteral feeding tube, 100 calories = 1 unit.  LCD
  2. of units billed = 440
    Date of Service: 05/09/10 – 05/31/10
    • Received – MD signed and dated orders for change in calorie requirements and feeding pump/supplies; signed and dated Revised DIF for enteral feedings; Registered Dietician progress notes supporting difficulty swallowing and aspiration risk; nursing care flowsheets supporting feedings at 75cc/hr via g-tube; medication record supporting beneficiary insulin dependent and blood sugar testing; additional unsigned RD progress notes; lab reports; proof of delivery; supplier information on enteral feeding pump; and a response from the ordering physician on the claim stating, “not our patient, no chart in our office, please check physician of record.â€?
    • Missing – Clinical documentation by the treating physician supporting dysphagia to corroborate findings by the Registered Dietician (RD), diabetes management and continued medical management.
    • Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider�. It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals and test reports. This documentation must be available upon request.

• Section 1842(p)(4) of the Social Security Act: [i]n case of an item or service… ordered by a physician or a practitioner… 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.

• Program Integrity Manual 100-8 Ch 5.5.7: “For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the
necessity for the type and quantity of items ordered and for the frequency of use or replacement (if applicable). The information should include the patient’s diagnosis and other pertinent information including, but not limited to, duration of the patient’s condition, clinical course (worsening or improvement), prognosis,
nature and extent of functional limitations, other therapeutic interventions and results, past experience with related items, etc. If an item requires a CMN or DIF, it is recommended that a copy of the completed CMN or DIF be kept in the patient’s record. 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. There must be information in the patient’s medical record that supports the medical necessity for the item and substantiates the answers on the CMN (if applicable) or DIF (if applicable) or information on a supplier prepared statement or physician attestation (if applicable).�

• Program Integrity Manual 100-5 Ch “For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a hand written or an electronic signature. Stamp signatures are not acceptable.�

Page 4 of 4 CERT and You Issue #5 May 2011 Helpful Tools Need assistance for requesting medical records from the ordering/treating physicians? We have the letters for you! Just access the NHIC Web site. http://www.medicarenhic.com/dme/dmerc_cert_rec.shtml

 Look for additional LCD-specific “Dear Physician� letters in future newsletters!

Other helpful and useful website resources:

MR BulletinFAQs:

Current Local Coverage Determinations (LCD):

DME MAC A Supplier Manual:

Provider Compliance Educational information:
CMS CERT Web page:

Contact Alina Jimenez, your helpful CERT Coordinator! Alina can help you tackle various CERT-related questions
and/or concerns, such as:
• General CERT information
• Detailed review results of a CERT claim
• Explanation of a CERT related overpayment
• How to have a CERT overpayment re-reviewed
• Clarification of the type of documentation CERT is requesting
• Why you may still be receiving request letters for medical records when you have already submitted the

You may contact Alina at: 323-432-7840 or alina.jimenez@hp.com

Please have your CID# ready before you call.

Stay tuned for more CERT & You