The Centers for Medicare & Medicaid Services (CMS) has issued Transmittal 533/Change Request 8843 to the Medicare Program Integrity Manual to provide guidance to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) as to what documentation is required when conducting medical review of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) repair claims. This guidance for repairs is to be applied to all DMEPOS equipment owned by Medicare beneficiaries; the effective date is November 4, 2014.
If Medicare paid for the base equipment initially, medical necessity for the base equipment has been established, according to the transmittal. Therefore, contractors are to review only the necessity of the repair and make a payment determination. The DME MAC shall ensure that the supplier’s documentation records support the need to restore the equipment to functionality to meet the beneficiary’s medical need. Medicare contractors shall not require a face-to-face examination for repair of DMEPOS items already covered and paid for by Medicare. However, documentation from the physician or treating practitioner that indicates the DMEPOS item being repaired continues to be medically necessary is required. Documentation is considered timely when it is on record in the preceding 12 months, unless otherwise specified in relevant Medicare policy.