Providing Medicare Covered Drugs – Documentation Requirements

The National Government Services, Jurisdiction B Medical Review department has recently been reviewing various drug claims and found common errors in regards to the orders and documentation requirements. This article is to provide information clarifying these issues.

Orders:
There are two types of orders that can be obtained, a dispensing order (verbal or preliminary written) or a detailed written order. The detailed written order can serve as the dispensing order but the dispensing order cannot serve as a detailed written order. For items that are dispensed based on a verbal or preliminary written order, the supplier must obtain a detailed written order prior to claim submission.

A dispensing order for drugs must include at a minimum the following components:

• Beneficiary name
• Description of the item provided
  • Name of drug, concentration (if applicable), dosage, frequency of administration, quantity dispensed or duration of use, and duration of infusion (if applicable)>
• Physician name
• Date of the order
• For verbal orders, name of person receiving the order
  The use of “prn” or “as needed” alone, are not acceptable for frequency of administration

A detailed written order for drugs must include all of the components of the dispensing order but must be signed and dated by the treating physician. If it is signed after the day that the drug is dispensed (i.e., after the date of service on the claim), the start date must be specified. The use of signature or date stamps is not acceptable.

A new detailed written order is required when there is a change in the order for the drug (dosage, strength, frequency, etc.), if there is a change in supplier, or if there are any state law requirements.
Many state pharmacy laws do not require that a verbal order be followed up by a detailed written order but Medicare requires that a detailed written order be obtained prior to claim submission. Please refer to the Program Integrity Manual, Publication 100-08, Chapter 5, for more information regarding Medicare order requirements.

Documentation:
If a development letter is received asking for medical records and/or documentation of medical necessity, those records must be obtained from the ordering physician. The documentation can be in the form of physician’s office records, hospital records, or nursing home records. The supporting documentation must be in the treating physician’s typical narrative format. A supplier generated form, even if completed and signed by the physician, will not stand alone in an audit situation. The documentation should support the diagnosis and/or medical condition that necessitates the drug provided. Failure to provide this information if it is requested will result in denial of the claim or request for an overpayment.

Posted 11/25/08