5.Signature Requirements

For medical review purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable.

The Medicare Program Integrity Manual notes several exceptions to normal signature requirements, as listed below:

EXCEPTION 1: Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.

EXCEPTION 2: There are some circumstances for which an order does not need to be signed. For example, orders for some clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and Pub.100-02 chapter 15, §80.6.1 state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation (e.g., a progress note) by the treating practitioner that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.

EXCEPTION 3: Other regulations and the CMS’ instructions regarding conditions of payment related to signatures (such as timeliness standards for particular benefits) take precedence. For medical review purposes, if the relevant regulation, NCD, LCD and CMS manuals are silent on whether the signature needs to be legible or present and the signature is illegible/missing, the reviewer shall follow the guidelines listed in the Medicare Program Integrity Manual, Chapter 3 to discern the identity and credentials (e.g., MD, RN, etc.) of the signator. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.

EXCEPTION 4: CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.

6. Refills of DMEPOS Items Provided on a Recurring Basis

For DMEPOS items and supplies that are provided on a recurring basis, billing must be based on prospective, not retrospective use. The following scenarios are illustrative of this concept:

Scenario 1: The treating practitioner writes an order for enteral nutrition which translates into the dispensing of 100 units of nutrient for one month. The supplier receives the order, delivers 100 units, and bills the claim with a date of service as the date of delivery indicating 100 units. This is an example of prospective billing and is acceptable.

Scenario 2: The treating practitioner writes an order for enteral nutrition which translates into the dispensing of 100 units of nutrient for one month. The supplier receives the order and delivers 100 units. A claim is not billed. At the end of the month, the supplier determines that the beneficiary used 90 units for the month and delivers 90 units to replace the nutrient used. A claim is then submitted with a date of service as the date of delivery indicating 90 units of enteral nutrition. This is an example of retrospective billing and is not acceptable.

For DMEPOS products that are supplied as refills to the original order, you must contact the beneficiary or caregiver/designee prior to dispensing the refill and not automatically ship on a pre-determined basis, even if authorized by the beneficiary. This shall be done to ensure that the refilled item remains reasonable and necessary, to ensure existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order. Contact with the beneficiary or designee regarding refills must take place no sooner than 14 calendar days prior to the delivery/shipping date. Items delivered without a valid, documented refill request will be denied as not reasonable and necessary.

You must not dispense a quantity of supplies exceeding a beneficiary’s expected utilization. You must stay attuned to changed or atypical utilization patterns on the part of their clients. You must verify with the prescribing practitioner that any changed or atypical utilization is warranted.

For delivery of refills, you must deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product. This is regardless of which delivery method is utilized. DME MACs allow for the processing of claims for refills delivered/shipped prior to the beneficiary exhausting his/her supply.

REFILL DOCUMENTATION

A routine refill prescription is not needed. A new prescription is needed when:

  • There is a change of supplier, and the new supplier is unable to obtain a copy of a valid order and documentation from the original supplier.
  • There is a change in the order for the accessory, supply, drug, etc.
  • When an item is replaced.
  • On a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy.

For items that the beneficiary obtains 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 that are delivered to the beneficiary, documentation of a request for refill must be either a written document received from the beneficiary or a contemporaneous written record of a phone conversation/contact between you and the beneficiary. The refill request must occur and be documented before shipment. A retrospective attestation statement by you or the beneficiary is not sufficient. The refill record must include:

  • The beneficiary’s name or authorized representative, if different than the beneficiary.
  • A description of each item that is being requested.
  • Date of refill request.
  • For consumable supplies, i.e., those that are used up (e.g., ostomy or urological supplies, surgical dressings, etc.)—you must assess the quantity of each item that the beneficiary still has remaining, to document that the amount remaining will be nearly exhausted on or about the supply anniversary date.
  • For non-consumable supplies, i.e., those more durable items that are not used up but may need periodic replacement (e.g., positive airway pressure and respiratory assist devices’ supplies)—you must assess whether the supplies remain functional, providing replacement (a refill) only when the supply item(s) is no longer able to function. You must document the functional condition of the item(s) being refilled in sufficient detail to demonstrate the cause of the dysfunction that necessitates replacement (refill).

This information must be kept on file and be available upon request.

Note: Some policies may require additional documentation. Refer to the appropriate LCD for guidance.

7. Beneficiary Authorization

You may only receive Medicare payment if the beneficiary assigns his or her Medicare benefits to you. Regulations authorize Medicare to pay for claims submitted by a supplier only if the beneficiary or the person authorized to request payment on the beneficiary’s behalf assigns the claims to the supplier and the supplier accepts assignment. For all claims submitted on or after January 1, 2005, payment shall be made to physicians and suppliers even without a beneficiary-signed assignment of benefits (AOB) form when the service can only be paid on an assignment related basis. This includes any mandatory assignment situations and participating physician or supplier situations. When you accept assignment, you must accept Medicare’s determination of the approved amount as the full fee for the service(s) rendered. For more information about beneficiary authorization, see the Chapter 6 of this manual.

8. Proof of Delivery (POD)

SUPPLIER PROOF OF DELIVERY DOCUMENTATION REQUIREMENTS

You are required to maintain proof of delivery documentation in your files. Documentation must be maintained in your files for seven years.

Proof of delivery is one of the supplier standards as noted in 42 CFR, 424.57(c)(12) and in Chapter 2 of this manual. In certain instances, compliance with proof of delivery may be required as a condition of payment and must be available to the DME MAC, RAC, SMRC, CERT, and UPIC on request. For such items, if the supplier does not have appropriate POD documentation within the prescribed timeframes, associated claims will be denied and overpayments will be recouped. Note that non-compliance with supplier standards may also result in revocation from the Medicare program. If you consistently do not provide documentation to support your services, you may be referred to the Office of Inspector General or NSC for investigation and/or imposition of sanctions.

PROOF OF DELIVERY AND DELIVERY METHODS

For the purpose of the delivery methods noted below, designee is defined as:

“A person who can sign and accept the delivery of durable medical equipment on behalf of the beneficiary.”

You, your employees, or anyone else having a financial interest in the delivery of the item are prohibited from signing and accepting an item on behalf of a beneficiary (i.e., acting as a designee on behalf of the beneficiary). The relationship of the designee to the beneficiary should be noted on the delivery document that you obtain (i.e., spouse, neighbor, etc.). The signature of the designee should be legible. If the signature of the designee is not legible, you (or the shipping service) should note the name of the designee on the delivery document.

There are three methods of delivery:

  1. Delivery directly to the beneficiary or authorized representative
  2. Delivery via shipping or delivery service
  3. Delivery of items to a nursing facility on behalf of the beneficiary

Regardless of the method of delivery, the contractor must be able to determine that the item(s) delivered are the same item(s) submitted for Medicare reimbursement and that the item(s) are received by a specific Medicare beneficiary.

Method 1—Direct Delivery to the Beneficiary

You may deliver directly to the beneficiary or the designee. In this case, POD to a beneficiary must be a signed and dated delivery document. The POD document must include:

  • Beneficiary’s name
  • Delivery address
  • A description of the item(s) being delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number.
  • Quantity delivered
  • Date delivered
  • Beneficiary (or designee) signature

The date delivered on the POD must be the date that the DMEPOS item was received by the beneficiary or designee. The date of delivery may be entered by the beneficiary, designee, or you. When your delivery documents have both your entered date and a beneficiary or beneficiary’s designee signature date on the POD document, the beneficiary or beneficiary’s designee-entered date is the date of service. In instances where the supplies are delivered directly by you, the date the beneficiary received the DMEPOS supply must be the date of service on the claim.

Method 2—Delivery via Shipping or Delivery Service Directly to a Beneficiary

If you utilize a shipping service or mail order, the POD documentation must be a complete record tracking the item(s) from you to the beneficiary. An example of acceptable proof of delivery would include both your detailed shipping invoice and the delivery service’s tracking information. Your record must be linked to the delivery service record by some clear method like the delivery service’s package identification number or your invoice number for the package sent to the beneficiary.

The POD document must include:

  • Beneficiary’s name
  • Delivery address
  • Delivery service’s package identification number, your invoice number, or alternative method that links your delivery documents with the delivery service’s records
  • A description of the item(s) being delivered. The description can be either a narrative description (e.g., lightweight wheelchair base), a HCPCS code, the long description of a HCPCS code, or a brand name/model number.
  • Quantity delivered
  • Date delivered
  • Evidence of delivery

If you utilize a shipping service or mail order, you must use the shipping date as the DOS on the claim. The shipping date may be defined as the date the delivery/shipping service label is created or the date the item is retrieved for delivery. However, such dates should not demonstrate significant variation.

You may also utilize a return postage-paid delivery invoice from the beneficiary or designee as a POD. This type of POD document must contain the information specified above.

Method 3—Delivery to Nursing Facility on Behalf of a Beneficiary

For items directly delivered by you to a nursing facility or when a delivery service or mail order is used to deliver the item(s) to a nursing facility, then you must have:

  1. Documentation demonstrating delivery of the item(s) to the facility by you or delivery entity; and
  2. Documentation from the nursing facility demonstrating receipt and/or usage of the item(s) by the beneficiary. The quantities delivered and used by the beneficiary must justify the quantity billed.

This information must be available upon request.

EXCEPTIONS

Exceptions to the preceding statements concerning the date(s) of service on the claim occur when the items are provided in anticipation of discharge from a hospital or nursing facility. You may deliver DME, prosthetic, or orthotic items, but not supplies or drugs, to a beneficiary in a hospital or nursing facility for the purpose of fitting or training the beneficiary in the proper use of the item. This may be done up to two days prior to the beneficiary’s anticipated discharge to their home. You must bill the date of service on the claim as the date of discharge and shall use the Place of Service (POS) as 12 (home). The item must be for subsequent use in the beneficiary’s home. No billing may be made for the item on those days the beneficiary was receiving training or fitting in the hospital or nursing facility.

Example:

  1. A beneficiary is admitted to a hospital stay on June 1.
  2. The beneficiary will require the use of a walker upon discharge and must be trained on its use while in the hospital. The walker is provided to the beneficiary in the hospital on June 5.
  3. The beneficiary is discharged from the hospital on June 6.

    You would then bill the claim to the DME MAC using June 6 as the date of service.

You may not bill for drugs or other DMEPOS items used by the beneficiary prior to the beneficiary’s discharge from the hospital or a Medicare Part A nursing facility stay. Billing the DME MAC for drugs, surgical dressings, urological supplies, or ostomy supplies that are provided in the hospital or during a Medicare Part A nursing facility stay is not allowed. These items are payable to the facility under Part A of Medicare. This prohibition applies even if the item is worn home by the beneficiary from the hospital or nursing facility. Any attempt by you and/or facility to substitute an item that is payable to you for an item that, under statute, should be provided by the facility, may be considered to be fraudulent. These statements apply to durable medical equipment delivered to a beneficiary in hospitals, skilled nursing facilities (Place of Service = 31), or nursing facilities (Place of Service = 32).

You may deliver a DMEPOS item to a beneficiary’s home in anticipation of a discharge from a hospital or nursing facility. You may arrange for actual delivery of the item approximately two days prior to the beneficiary’s anticipated discharge to their home. You must bill the date of service on the claim as the date of discharge and use the Place of Service (POS) as 12 (home).

Equipment Retained From a Prior Payer

When a beneficiary receiving a DMEPOS item from another payer (including a Medicare Advantage Plan) becomes eligible for the Medicare FFS program, the first Medicare claim for that item or service is considered a new initial Medicare claim for the item. Even if there is no change in the beneficiary’s medical condition, the beneficiary must meet all coverage, coding, and documentation requirements for the DMEPOS item in effect on the date of service of the initial Medicare claim.

A POD is required for all items, even those in the beneficiary’s possession provided by another insurer prior to Medicare eligibility. To meet the POD requirements for a beneficiary transitioning to Medicare you, the supplier, must document:

  • A statement, signed and dated by the beneficiary (or beneficiary’s designee), that you have examined the item, meets the POD requirements; and
  • A supplier attestation that the item meets Medicare requirements.

For the purposes of reasonable, useful lifetime and calculation of continuous use, the first day of the first rental month in which Medicare payments are made for the item (i.e., date of service) serves as the start date of the reasonable, useful lifetime and period of continuous use. In these cases, the proof of delivery documentation serves as evidence that the beneficiary is already in possession of the item.

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