News from the AOA's Blog

Edited by Chuck Brownlow, O.D., Medical Records consultant

Question: What’s this about a $505 fee that we have to pay in order to continue to supply post-op glasses to our cataract patients? 

Answer: Several months ago, the Centers for Medicare & Medicaid Services (CMS) announced that all Medicare providers and suppliers would have to pay a fee when they enroll or re-enroll. The AOA helped obtain an exemption from Congress for physicians, but the CMS decided not to extend the exemption to physicians who enroll as suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). All DMEPOS suppliers are required to re-enroll periodically and to pay a re-enrollment fee, currently $505, when their re-enrollment date comes around. No action is necessary until practitioners are informed by the National Supplier Clearinghouse that it’s time for them to re-enroll. They can continue to provide post-op glasses for cataract patients in the meantime. Our best information suggests that re-enrollment will be required every three years. 

Question: How about a situation in which I am already enrolled in Medicare, with a PECOS (Medicare Provider Enrollment, Chain, and Ownership System) record, have a Type 1 “Individual” National Provider Identifier (NPI), and am a provider for Medicare Part B, but my dispensary is a separate business entity, has its own tax ID number, its own Type 2 “Entity” NPI, and has chosen to not enroll as a supplier for DMEPOS? Can the dispensary still supply the post-op glasses to Medicare patients?

Answer: Yes. Pracitioners are qualified to write the order for the glasses and their dispensaries may supply the glasses, though the patient must agree to pay them directly for the glasses and will not receive any reimbursement from Medicare for the materials. The pracitioner needs to carefully explain the situation to the patient before ordering the glasses and should have the patient sign an Advance Beneficiary Notice (ABN), indicating that she/he understands the ruling and has decided to pay for the glasses her/himself. The practitioners would submit a claim to the DME contractor for their region on behalf of the patient, adding the -GY modifier indicating that the services/materials are statutorily excluded and not covered by Medicare. 

The alternative for the patient would be to take the prescription to a dispensary that is enrolled with Medicare, present the prescription to the dispensary and request his or her covered glasses there. In that case, the patient would receive reimbursement for the glasses from Medicare. Practitioners will probably have some loyal patients who choose to stay with them and order glasses through their dispensary, paying for the glasses themselves, and others who will seek the Medicare benefit and have the prescription filled elsewhere.

Note: In general, all services and materials are either “covered” by Medicare or “not covered.” Post-operative glasses for cataract patients, one pair per eye, are normally considered to be covered. When the glasses are provided based on a prescription written by a physician who does not have a Medicare enrollment record in PECOS or by a supplier that is not enrolled in DMEPOS, the normally “covered” services and materials will be classified “not covered,” and payment is the responsibility of the patient.
 
Question: I’ve always scribbled my initials at the bottom of each patient’s record…is that still all right?

Answer: Short answer… probably not. Medicare and most other insurers follow the general rules for medical records that are found in Current Procedural Terminology (CPT© American
Medical Association) and in the Documentation Guidelines for the Evaluation & Management Services, 1997. The Documentation Guidelines consider it critical that each record includes the “legible identity of the observer.” Medicare and many other insurers require that the doctor responsible for the care of the patient affix a signature to each record. The signature may be written or it may be electronic, as in the case of electronic health care records, but it must be a signature. In any case, initials do not fulfill an insurer’s requirement for “legible identity” or “signature,” and in an audit, “No Signature” will probably mean “No Pay!”

Note regarding electronic signatures: There are several acceptable methods for “signing” an electronic chart, varying from one electronic health record software to another. These may include user name/ password codes, signature pad, etc. If a practitioner’s EHR software permits electronic signatures, be sure to verify with them that the method is acceptable to insurers and Medicare. 

My suggestion is that every record should be signed by the person responsible for its content (written or electronic), and the signature should be accompanied by a printed/stamped/carefully hand-written name of the person as well.
 That way, all payers’ requirements will be fulfilled and practitioners will be less likely to be hassled in an audit for not having proper documentation.

As an alternative, some insurers will accept a signature log, in which each provider’s signature is scrawled by the individual, with the name carefully printed or typed next to the illegible real signature. The key with a signature log is to keep it up to date, as signatures can change over time, and to be sure the log includes all people currently signing records or other documents on behalf of the practice.

Some insurers, including many Medicare carriers, require that the signature itself is actually legible.

As many providers have experienced challenges from auditors due to illegible signatures, it may be necessary for practitioners to actually sign their name on each record in careful cursive, totally readable, to comply with the rules of payers whose rules specifically require a “legible signature” of the provider.