Documentation of a Dispensing Order (If Item Is Delivered Based on a Dispensing Order)

Documentation of a Dispensing Order (If Item Is Delivered Based on a Dispensing Order)

Suction Pumps (E0600 andE2000)
Catheters (4605 and A4624)
Saline Solution (A4216 and A4217)
Reference: LCD L11494 and PA A25376
Required Documentation in Supplier's File
All Claims for Suction Pumps
  • Documentation of a dispensing order (if item is delivered based on a dispensing order) that contains:
  • Description of the item
  • Beneficiary’s name
  • Prescribing physician’s name
  • Date of the order and the start date, if the start date is different from the date of the order
  • Physician signature (if written order) or supplier signature (if verbal order)
Note: A dispensing order is only required if the item(s) is dispensed prior to obtaining the detailed written order. Suppliers should not submit claims prior to obtaining a valid detailed written order. Items billed before a signed and dated order has been received must be submitted with modifier EY.
  • Valid detailed written order that contains:
  • Beneficiary's name
  • Physician's name
  • Date of the order and the start date, if start date is different from the date of the order
  • Detailed description of the item(s) to be dispensed
  • Quantity to be dispensed
  • Number of refills
  • Physician’s signature and signature date
  • Beneficiary authorization
  • Request for refill documentation
  • For items obtained in-person at a retail store, the signed delivery slip or a copy of the itemized sales receipt is sufficient documentation of a request for refill.
  • For items delivered to the beneficiary, there must be documentation of a request for refill to ensure that the refilled item remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order.
  • A written document received from the beneficiary; or
  • A contemporaneous written record of contact between the supplier and beneficiary that takes place no sooner than 14 calendar days prior to the delivery/shipping date and includes:
  • Beneficiary's name or authorized representative if different than the beneficiary
  • A description of each item that is being requested
  • Date of refill request
  • Information documenting that the beneficiary's remaining supply is approaching exhaustion by the expected delivery date.
  • Continued use
  • Any of the following may serve as documentation that an item submitted for reimbursement continues to be used by the beneficiary:
  • Timely documentation in the beneficiary’s medical record showing usage of the item, related option/accessories and supplies.
  • Supplier records documenting the request for refill/replacement of supplies in compliance with the Refill Documentation Requirements. This is deemed to be sufficient to document continued use for the base item, as well.
  • Supplier records documenting beneficiary confirmation of continued use of a rental item.
  • Continued medical need
  • For ongoing supplies and rental DME items there must be information in the beneficiary’s medical record to support that the item continues to be used by the beneficiary and remains reasonable and necessary.
  • Any of the following may serve as documentation justifying continued medical need:
  • A recent order by the treating physician for refills
  • A recent change in prescription
  • Timely documentation in the beneficiary’s medical record showing usage of the item.
NOTE: Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in the policy.
  • Proof of delivery (POD)
    Suppliers are required to maintain POD documentation in their files.
  • Method 1–Direct Delivery to the Beneficiary by the Supplier
    Suppliers may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery slip. The POD record must include:
  • Beneficiary's name
  • Delivery address
  • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description)
  • Quantity delivered
  • Date delivered
  • Beneficiary (or designee) signature and date of signature
NOTE: The signature date on the delivery slip must be the date the item was received by the beneficiary or designee.
  • Method 2–Delivery via Shipping or Delivery Service Directly to a Beneficiary
    If the supplier utilizes a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from the DMEPOS supplier to the beneficiary. The POD record must include:
  • Beneficiary's name
  • Delivery address
  • Delivery service's package identification number, supplier invoice number or alternative method that links the supplier's delivery documents with the delivery service's records.
  • Sufficiently detailed description to identify the item(s) being delivered (e.g., brand name, serial number, narrative description)
  • Quantity delivered
  • Date delivered
  • Evidence of delivery
NOTE: If a supplier utilizes a shipping service or mail order, suppliers must use the shipping date as the date of service on the claim.
Claims for Respiratory Suction Pumps (E0600)
  • Documentation that supports that the beneficiary has difficulty raising and clearing secretions secondary to one of the following:
  • Cancer or surgery of the throat or mouth, or
  • Dysfunction of the swallowing muscle, or
  • Unconsciousness or obtunded state, or
  • Tracheostomy.
Claims for Tracheal Suction Catheters (A4624)
  • Beneficiary has a tracheostomy described by ICD-9 codes 519.00, 519.01, 519.02, 519.09, V44.0 or V55.0 and
  • Beneficiary requires the use of a covered respiratory pump (E0600) for tracheostomy suctioning.
Claims for Closed System Catheters (A4605)
  • Beneficiary has a tracheostomy described by ICD-9 codes 519.00, 519.01, 519.02, 519.09, V44.0 or V55.0 and
  • Beneficiary requires the use of a covered respiratory pump (E0600) for tracheostomy suctioning and
  • Beneficiary requires the use of a covered ventilator
Claims for Sterile Saline Solution (A4216, A4217)
  • The saline is being used to clear a suction catheter after tracheostomy suctioning. (Sterile saline is not covered for oropharyngeal suctioning.)
Claims for Gastric Suction Pumps (E2000)
  • Documentation to support the beneficiary is unable to empty gastric secretions through normal gastrointestinal functions.
Billing Reminders
  • When billing for tracheal suction catheters (HCPCS codes A4605 and A4624) in beneficiaries with a tracheostomy, ICD-9 code 519.00, 519.01, 519.02, 519.09, V44.0 or V55.0 must be entered on the claim.
  • Sterile suction catheters (A4624) are only medically necessary for tracheostomy suctioning. No more than three suction catheters per dayare covered for medically necessary tracheostomy suctioning.
  • Oropharyngeal suctioning is not a sterile procedure. No more than three catheters per weekare covered for medically necessary oropharyngeal suctioning.
  • When billing for quantities of supplies greater than those described in the Indications and Limitations of Coverage and/or Medical Necessity there must be adequate, clear documentation in the beneficiary’s medical records corroborating the medical necessity of this amount. The DME MAC may request copies of the beneficiary’s medical records that corroborate
  • Tracheal suction catheters and sterile saline used for suctioning are considered DME supplies and are therefore not covered in nursing facilities (Place of Service Codes 31 and 32).
* NOTE: It is expected that the beneficiary’s medical records will reflect the need for the care provided. These records are not routinely submitted but must be available upon request. Therefore, while it is not a requirement, it is a recommendation that suppliers obtain and review the appropriate medical records and maintain a copy in the beneficiary’s file.
DISCLAIMER
The content of this document was prepared as an educational tool and is not intended to grant rights or impose obligations. Use of this document is not intended to take the place of either written law or regulations.
Updated: April 17, 2013
© 2013 Noridian Healthcare Solutions, LLC.
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