Documentation

Documentation A. The Division of Medicaid requires that the beneficiary and/or the legal guardian, with medically appropriate assistance from the ordering physician, have freedom of choice to select the durable medical equipment (DME) provider and must be informed of all DME, medical appliances, services and charges to be billed to the Division of Medicaid. B. The following must be available to the Division of Medicaid at all times: 1. DME licenses, 2. Permits, 3. Ownership information, 4. Employee roster of current and past employees, 5. DME Surety Bond information, and 6. Original purchase invoices for DME, medical appliances and supplies. C. DME providers must maintain a record for each beneficiary that is located at the DME’s office or can be accessed from the DME provider's office and must contain, at minimum, the following information: 1. Documentation by a physician which includes: a) That a face-to-face encounter related to the primary reason the beneficiary requires DME and medical appliances occurred no more than six (6) months prior to the start of services, b) The practitioner who conducted the encounter, and c) The time and date of the encounter. 2. If the face-to-face encounter is conducted by an allowed non-physician practitioner as defined in Miss. Admin Code Part 209, Rule 1.3: a) The allowed non-physician practitioner performing the face-to-face encounter must communicate the clinical findings of the face-to-face encounter to the ordering physician. b) The clinical findings of the face-to-face encounter must be incorporated into a written or electronic document in the beneficiary's medical record. 3. A copy of the completed Certificate of Medical Necessity and Plan of Care for each item when required by the Utilization Management and Quality Improvement Organization (UM/QIO), the Division of Medicaid or designated entity, which must include: a) Date of request, b) Diagnosis of beneficiary, c) Type(s) of DME and/or medical appliance, and d) Anticipated length of need. 4. A copy of the original prescription from the ordering physician for each item. 5. The date of delivery, method of delivery, and proof of delivery (POD) for each DME item and/or medical appliance. a) For each item sent directly by the DME provider, the proof of delivery (POD) signed and dated by the DME provider's technician or representative for each item which must include: 1) Beneficiary's name, 2) Delivery address, 3) Detailed description of the DME, medical appliances and/or services provided at that time and Healthcare Common Procedure Coding System (HCPCS) codes that identify the item being delivered, 4) Quantity delivered, 5) Date of delivery which must be the date the beneficiary received the item, and 6) Signature of beneficiary or designated representative. a) During a national or statewide emergency, a signature is not required. b) During a national or statewide emergency, the provider must document the emergency and confirmation of delivery by an alternate means including, but not limited to: (1) Telephone, (2) Text message, or (3) Other electronic communication. b) For each item sent via a shipping service, the POD must include: 1) Beneficiary's name 2) Delivery address, 3) Delivery service's package identification number, supplier invoice number or alternative method that links the supplier's delivery documents or purchase order to the delivery service's record, 4) Detailed description with HCPCS codes that identify the item being delivered, 5) Quantity delivered, 6) Date shipped, 7) Date of delivery, 8) Evidence of delivery which must include a tracking log that identifies each individual package with a unique identification number and delivery address. 6. Record of the manufacturer or brand of each item, and quantity/units of each item supplied. 7. Reason or description and date for each and every repair or maintenance procedure on DME and/or medical appliance in the possession of the beneficiary or returned to the DME company for repair or maintenance; and if out of the possession of the beneficiary, the time period it was unavailable for his/her use and any arrangements made to accommodate the beneficiary during the time period. 8. A record for each item that indicates if the item is new or used, manufacturer’s name, model number or name, serial number if marked on the device, any optional attachments, enhancements, or improvements added by the manufacturer or DME provider which results in an increased charge amount that supports the justification for and proves the delivery of the complete DME and/or medical appliance product as billed to and paid by The Division of Medicaid or Medicare. 9. Records of any maintenance supplies delivered and/or used. 10. For customized DME and/or medical appliances, the name(s), business name and address, and telephone number of the therapist or technician who determines the measurements necessary to modify, build, or complete the custom item. 11. Copies of any specialized documents including but not limited to: a) An environmental assessment if needed for potential accommodation of DME and/or medical appliance. b) Any teaching, training or instruction given to beneficiary/caregiver and response. 12. Documentation that the beneficiary's need for the DME and/or medical appliance is reviewed annually by a Medicaid enrolled physician. D. The physician ordering the DME, medical appliance, or medical supply must maintain documentation relating to the medical necessity for each item. 1. The information must be recorded in the beneficiary’s medical record or on the appropriate Medicaid Certificate of Medical Necessity. 2. The physician must retain a copy of the completed Certificate of Medical Necessity in the file. E. Records must be documented and maintained in accordance with requirements set forth in Miss. Admin Code Part 200, Chapter 1, Rule 1.3.