2024 DMEPOS Series #1: Diabetic Test Strips

Standard Written Order (SWO):

• Beneficiaries name OR Medicare Beneficiary Identifier (MBI)
• The order date – this cannot be stamped
• A detailed description of the items ordered
• The quantity to be dispensed
• Treating practitioner’s name OR NPI
• Treating practitioner’s signature – this cannot be stamped

Dispensing/Proof of Delivery:

• Beneficiary name
• Delivery address
• Detailed description of the item(s)
• Quantity delivered
• Date delivered – must match the date of service billed
• Signature of beneficiary or representative

Delivery/Mailing:

• When delivering or mailing test strips to Medicare beneficiaries, the pharmacy must have a proof of refill request (PORR) and affirmative response from the beneficiary or their representative including, at minimum:
• Requestor’s name (beneficiary or authorized representative)
• A description of each item being requested
• Documentation of an affirmative response indicating a need for the refill
• Includes confirmation that the beneficiary is still using the item
• No changes have been made to the order
• A refill is needed
• Date of the request
• DMEPOS items and supplies that are provided on a recurring basis must be based on prospective, not retrospective, use
• Contact with the beneficiary, or authorized representative, must take place no sooner than 30 calendar days before the expected end of the current supply

Medical Records:

• A covered diagnosis
• Testing frequency (including rationale and testing logs if the patient is exceeding Medicare guidelines)
• Continued need and use
• Signed by the treating practitioner

Billing:

• Bill the “Medicare/Medicaid” version of strips, when available
• Verify the NDC being billed is for the correct package size
• Attach the correct modifier – whether the patient is on insulin (KX) or not on insulin (KS)

PAAS Tips:

• While refills are not a required element on the SWO, if the practitioner writes for refills, they will be honored exactly as specified regardless of the total quantity written.
• If an order is for a 90-day supply with three refills (or 360 total days), and the patient requests a 30-day supply at a time, Medicare will only allow for the three additional fills.
  • Consider asking the prescriber to resend the SWO written for 30 days’ supply at a time plus an adjusted number of refills to avoid unauthorized refills.
• Any corrections to an SWO must be signed and dated by the prescriber prior to submitting a claim.
• If you call the prescriber’s office for a clarification to the order and document the clarification with a clinical note (e.g., MD clarified #30 with 11 refills is ok), that note should be counter-signed by the prescriber to validate the change. (This is not standard practice for non-DMEPOS claims, but DME MACs are enforcing this for Medicare Part B billing.)
• Alternatively, ask the prescriber to send a new SWO with the additional information.
• For an item that the beneficiary obtains in-person at your pharmacy, the signed delivery slip or copy of an itemized sales receipt is sufficient documentation for a refill request and affirmative response.
• The supplier must provide the DMEPOS product no sooner than 10 calendar days before the expected end of the current supply – regardless of whether the refill is picked up in the pharmacy or delivered.
• While obtain medical records prior to billing is rarely pragmatic, it is prudent to consider when patients are exceeding guidelines for testing (as prescribers may be unaware of requirements and subsequent Medical Records may be lacking sufficient detail for payment).
• If you have reason to believe the strips will not be covered by Medicare, consider obtaining a signed Advance Beneficiary Notice (ABN) of Non-coverage prior to dispensing.
• Allows the transfer of financial liability back to the patient in the event the claim is denied.
• ABN must be completely and appropriately filled out and specify the reason Medicare may deny the claim.
• ABN must be completed and signed on or prior to the date of service.
• Use all the tools and resources available on your local DME MAC website to ensure you are compliant with Medicare’s billing and documentation rules.