North Central OK Ostomy 2012-04 Medicare Reimbursement Rules

From North Central Oklahoma Ostomy Outlook April 2012:

Medicare Reimbursement Rules

Under new Medicare rules dated January 2011, it is the responsibility of your doctor to determine and document the medical need for all healthcare services. This information is required by your ostomy supply retailer in order for you to receive assignment of your bill from Medicare. In other words, Medicare is demanding more documentation and wants all ostomy patients to consult with their doctor on a yearly basis regarding the condition of their ostomy and continuing need for supplies.

For Ostomy Supplies to be covered by Medicare, the patient’s medical record must contain sufficient information about the patient’s medical condition to substantiate the necessity for the type and quantity of items ordered and for the frequency of use or replacement. The ordering physician is responsible for the following:

A detailed order* that includes the following:
1. Patient Name
2. The type of supplies ordered
3. The quantity used per unit of time
4. The ordering physician’s legible signature
5. The date of the ordering physician’s signature
6. The duration of need
*Note: An order that only states “as needed” will result in those items being denied as not medically necessary. Also, a new order is required if there is an increase in the quantity of the supply used per month.
Clinical records that document the medical necessity and the need for the quantity of items provided.
A payable diagnosis.

Statements that the physician writes in the patient’s medical records and sends to the ostomy supply dealer may include language such as the following:

“I have reviewed my patient _______ and his/her ostomy and it is functioning properly. He/she continues to need supplies for the management of the ostomy including skin barriers, pouches, deodorant, skin preparations, belts, pastes, powders and barrier rings [list those actually needed, with quantities]. This patient is using a one-piece [or two-piece] drainable [or closed] ostomy pouching system with standard wear [or extended wear] barrier and may change up to xx times a month.”

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This page last revised 2012-04-09

This article appeared in the North Central Oklahoma newsletter Ostomy Outlook. If you'd like to receive this newsletter on a regular basis, please Sign Up for our Newsletter Email List.