When Medicare Says You Didn’t Write an Order to Yourself
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The other day, a physician who is also a certified coder called me with a Medicare audit problem that had him stumped.
His AFO claim had been denied because the DME MAC stated there was no Standard Written Order, or SWO, and no qualifying face-to-face encounter within the required timeframe. He was frustrated, and for good reason. He was both the prescriber and the supplier. In his mind, requiring a separate SWO meant Medicare expected him to write an order to himself.
That sounds silly because, in that limited circumstance, it is.
The good news is that the answer is not buried in some mysterious Medicare memo. It is right there in the CMS documentation. The problem is that most people do not download, read, or keep these documents handy until an audit forces them to.
Let’s start with the SWO.
A Standard Written Order is essentially Medicare’s version of a prescription. For DMEPOS claims, CMS says the SWO must include the beneficiary’s name or Medicare Beneficiary Identifier, the order date, a general description of the item, quantity if applicable, the treating practitioner’s name or NPI, and the treating practitioner’s signature. The item description can be a general narrative, HCPCS code, HCPCS narrative, brand name, or model number.
In the ordinary supplier-prescriber relationship, that order must be communicated to the supplier before the claim is submitted. For certain items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, the order must be completed before delivery.
But here is the key language for physicians who prescribe and supply certain DMEPOS items to their own patients:
CMS states that “In the limited circumstances when the treating practitioner is also the supplier and is permitted to furnish the specific DMEPOS item under applicable laws and policies, a separate SWO is not required. However, the medical record must still contain all the required SWO elements.”
This language is contained in several obscure CMS documents, one of which is entitled “Standard Documentation Requirements”. There just so happens to be a link to this document at the bottom of every DME LCD policy (See below). CMS said the same thing even more plainly in MLN Matters MM10984: MACs will look to the entire medical record to determine whether the order elements are present, and they will not expect the practitioner to write a separate order to himself or herself.
That does not mean you can ignore the SWO elements. It means you do not necessarily need a separate document called “Standard Written Order” when you are both the treating practitioner and the permitted supplier. Your chart still has to contain the patient identifier, date, item description, quantity if applicable, your name or NPI, and your signature.
The practical solution is simple. Either complete a separate SWO anyway, which is often the cleanest audit trail, or make sure your note or order form clearly contains every required element. If you are using a KevinRoot order form, make sure it includes the required SWO elements and consider labeling it “Standard Written Order.” If you are relying on the treating-practitioner-as-supplier exception, keep the Standard Documentation Requirements article (with your appeal materials).
Now let’s talk about the face-to-face issue.
For DMEPOS items on the Required Face-to-Face Encounter and Written Order Prior to Delivery List, CMS requires a face-to-face encounter within six months before the order or prescription. The encounter must support payment for the item and must be documented in the medical record with subjective and objective, patient-specific information used to diagnose, treat, or manage the condition requiring the DMEPOS item.
This is where clinicians get understandably annoyed. We think, “I evaluated the patient. I documented the diagnosis. I documented the medical necessity. I saw the patient only a few weeks before delivery. Why are we pretending this did not happen?”
Because Medicare audit language does not always reward common sense. It rewards clear, unmistakable documentation.
The face-to-face encounter does not require a magical incantation, and CMS recognizes both in-person and qualifying telehealth encounters. But in the real world of audits, it helps to make the record painfully obvious. A simple sentence can prevent an unnecessary denial:
“Today I personally evaluated the patient face-to-face for the condition requiring the AFO. Based on the history, examination, diagnosis, functional limitations, and treatment plan documented above, the patient requires [specific AFO/HCPCS/narrative] for [clinical reason].”
That sentence should not replace your medical necessity documentation. It should point the auditor to it.
And yes, certain AFO codes are on the current CMS Required Face-to-Face Encounter and Written Order Prior to Delivery List, including L1932, L1940, L1951, L1960, and L1970. So for those items, the documentation burden is not theoretical. It is a condition of payment.
In this case, my colleague had evaluated the patient only a few weeks before delivery. The medical necessity appeared to be documented. The issue was that the auditor either did not recognize the treating-practitioner-as-supplier exception, did not find the SWO elements in the chart, did not identify the encounter as a qualifying face-to-face visit, or some combination of the three.
My recommendation was to appeal with the chart note, the order documentation, proof of delivery, the CMS Standard Documentation Requirements article, and MM10984. The appeal should specifically explain that the treating practitioner was also the supplier, that CMS does not require a separate SWO in that limited circumstance, and that the medical record contains the required order elements. It should also point directly to the visit note showing the patient was evaluated within the required timeframe and that the encounter supported medical necessity for the AFO.
This is one of those Medicare situations where the denial may be wrong, but the prevention strategy is still worth adopting.
Document the required SWO elements.
Clearly identify the face-to-face encounter.
Tie the exam, diagnosis, functional deficit, and device to medical necessity.
Use plain language that an auditor cannot miss. And they do miss these! Whether it’s because they are overworked and/or have a quota to fail claims, doesn’t matter. They truly are Lucy and Ethel in the Chocolate Factory!! And we want our claims to be paid on the initial submission or pass an auditor’s scrutiny on their first pass through!
Is it a little preposterous that we have to document the obvious? Of course. But this is the game we agreed to play when we agreed to bill Medicare. The goal is not to win a philosophical argument with the auditor. The goal is to get paid in a timely manner for medically necessary care and keep the chart strong enough so that the next audit does not become a project impinging on a robust revenue cycle.
I will let you know how his appeal turns out.
Standard Documentation Requirements May be found at:
https://www.cms.gov/medicare-coverage-database/view/article.aspx?articleid=55426
