As a supply item, Medicare and many other payers have defined refill requirements that must be followed when providing the items on an as-needed basis. Most of these requirements follow the same structured requirements:
- Continued medical need
- Request for refill for shipped supplies
- Proof of delivery
These requirements typically apply to patients who are established with their respective DMEPOS or O&P supplier, meaning the supplier previously provided the items that need to be refilled and/or the prosthesis for which the items are needed. If the patient is new to the supplier and requests a refill of supplies, it is in the supplier’s best interest to obtain compliant documentation, including basic coverage criteria supported by the treating practitioner’s (physician) medical records, as there isn’t a guarantee that the previous supplier obtained compliant documentation when the device was provided.
Technically, refills are covered under the original order for the device provided, assuming the supplies requested are the same HCPCS and the same (or less) quantity as reflected on the original order. If using the original order, continued medical need would be supported by current medical records reflecting that the patient is still using the device with no contradictory information documented. Although basic coverage criteria do not need to be documented for refills, if any information exists within the current medical records to suggest basic coverage criteria no longer exist, this could result in a claim denial. For this purpose, the definition of current medical records is less than 12 months old. As an alternative to current medical records and the original order, continued medical need can also be documented via a new order for the refill supplies. Current medical records are not required if a new order is being obtained for refills.
Supplies are one of the few prosthetic items that can be shipped to the patient. In this scenario, the proof of delivery documentation must follow Medicare’s Method 2 process for shipping items. Keep in mind that it would only be appropriate to ship prefabricated supplies. Custom fabricated liners must still be delivered in person, per the DMEPOS Quality Standards. When items are shipped, it is critical that suppliers document the patient’s request for those supplies. This can be documented in an administrative or clinical note in the patient’s chart and should include the following information:
- Patient’s name
- Supplies requested
- Date of request
- Affirmative response that the patient needs the supplies
Although not typically required, it is best practice to also document the functional condition of each type of item being refilled. This is particularly helpful in situations where frequency limitations have been exhausted for a supply item, and an appeal is necessary for payment of excess supplies.
In situations where the patient is coming into the clinic to pick up the supply items, the above-mentioned documentation of the request for refill is not required. A signed proof of delivery document is sufficient to justify the patient needs the items.
Following these documentation requirements for refills is critical to ensuring any supply claim is compliant to prevent unnecessary denials and/or recoupments.
Lesleigh Sisson, CFo, CFm, and Curt Bertram, CPO, are part of the leadership team at O&P Insight. Sisson and Bertram have a combined 64 years of experience in O&P administration, clinical services, and operational management. You can contact them at [email protected] or [email protected]. Michelle Wullstein, CPCO, has been in the Medicare profession for over 18 years and is an AAPC certified professional compliance officer and provides O&P specific medical policy, billing, documentation, and HIPAA compliance support to internal teams and clients. While every attempt has been made to ensure accuracy, The O&P EDGE is not responsible for errors.
