Unit 7: Medical Records Documentation Requirements

4.7 Medical Records Overview

4.7 Electronic Health Records

4.7 Documentation Requirements for All Providers

4.7 Additional Requirements to Support E/M Services

4.7 Hospital/Facility Services

4.7 Ancillary Services

4.7 Psychiatric Care, Psychotherapy, and Counseling

4.7 Opioid Addiction Management

4.7 Diagnostic and Therapeutic Testing

4.7 Therapy Services

4.7 Durable Medical Equipment, Prosthetics, Orthotics, & Suppliers

4.7 Disclaimers

4.7 Medical Records Overview

Highmark makes every effort to provide resources to assist providers in servicing our members and working with us. This unit of the manual was developed to provide guidelines for documenting members’ medical records that will help you to have the appropriate documentation readily available for medical necessity reviews. This will help us to ensure accuracy of billed claims data and, therefore, prevent delays in reviews and payment.

The content herein provides minimum standards for medical record detail necessary to document and support claims for services rendered to members. It is the provider’s responsibility to adhere to professional standards, as well as applicable laws, regulations, and directives, with respect to medical recordkeeping and when such obligations are not addressed in this Unit.

Please note that examples included within this Unit are general in nature.

Purpose of a Medical Record

A medical record must clearly document the medical care provided to a member. Medical record documentation is necessary to record applicable observations and findings regarding the member’s history, examinations, diagnostic tests and procedures, diagnoses, treatments and treatment plan, necessary follow-up care, and outcomes or responses to care per date of service or encounter.

Additionally, the medical record serves as a formal document and a communication tool between providers, vendors, and Highmark. All medical documentation must be maintained in the member’s medical record and, if requested, made available to Highmark or its contracted vendor by the requested date.

Benefit Applictaion

Coverage guidelines are determined according to individual or group customer benefits. All services reported for Highmark members must be supported within the medical record and all claims may be subject to medical review.

You should not routinely submit this documentation with your claims, except in circumstances when required. However, if requested, medical documentation must be made available to Highmark or its contracted vendor.

The medical record is expected to include such information as noted above and defined in the provider requirements within this Unit. Reimbursement may be denied for services that are not clearly documented within the member’s medical record.

Medical Record Retention

Providers are required to retain all records, including medical records, in accordance with the provider’s participation agreements and Highmark’s administrative requirements, as well as all applicable state and federal laws, Regulations, and governmental program requirements.

Important!

Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) providers are required to maintain records in accordance with prudent record-keeping procedures and as required by practice standards and law, but in no event shall any medical records be retained for less than six years for audit covered per and, with respect to minor covered persons, three years from majority or six years from the date of majority, as applicable, following termination or for such longer period as may be required by law.

Audits

All claims submitted, including those for risk adjustment and quality review purposes, are subject to internal and/or federal audit.

• Audits may be initiated by Highmark, the Centers for Medicare & Medicaid Services (CMS), National Committee on Quality Assurance (NCQA), or Health & Human Services (HHS) to determine accuracy and completeness of documented medical records.
• Providers are required to respond to all medical record requests in a timely manner and provide identified records.
• Providers are required to notify Highmark or file a corrected claim for any submissions they identify as erroneous.

Reminder: Refer Members to Network Participating Providers

Highmark contracted providers are strongly encouraged to refer members to providers participating in the member’s network. This protects the member from higher costs that may be incurred if services are received from a non-network provider.

If an out-of-network referral is necessary, the reason for the referral to an out-of-network provider must be documented in the member’s medical records.

For More Information

Please refer to Highmark’s Medical Policies and Reimbursement Policies for additional information. These can be accessed by selecting Policies & Programs (Medical Policies) or Claims & Authorization (Reimbursement Policies) on the Provider Resource Center.

4.7 Electronic Health Records

Electronic health records (EHRs) can help providers better manage care by enabling quick access to accurate, up-to-date, and complete information about their patients at the point of care. They also promote complete and legible documentation to improve productivity and efficiency in coding and billing.

Cloning and Copying Forward Not Permitted

Providers must ensure that every entry is accurate and unique to the individual member. Functions such as cloning, copy and paste, cookie cutter, copy forward, and carrying forward are similar in that using these features has the potential to create inaccuracies in documentation by using the same language from member to member.

Highmark strongly discourages cloning and copying forward because utilization of canned statements within the EHR may not reflect accurate clinical determinations if not reviewed carefully, as they may lead to the following issues:

• Potential for a false description of services rendered to the member
• Potential for medical errors by using outdated or inaccurate information
• Coding from old or outdated information may result in inaccurate coding

Inconsistencies as a result of cloning, copying, or pasting found during the review of a member’s medical record may result in denial of the claim.

Authenticate Records

Providers must authenticate records that have been written by others, especially when another individual (such as a scribe) types the documentation into the EHR. Errors may not be identified when the responsible providers signs the record without reading the content thoroughly.

Use of Addenda

Delayed entries within reasonable time frames may be appropriate for clarification, error correction, or for the addition of information not available at the time of the initial entry.

However, addenda are not to be used to add services reported at the time of the initial service or to retrospectively add information to justify medical necessity. In addition, using addenda to enhance documentation can cause medical records to be altered inappropriately.

Amending The Medical Record

If it is necessary to amend a medical record, the original documentation should not be deleted. Retain and clearly identify all original content.

Any edits to the medical record must be clearly and permanently identified as such – as an amendment, delayed entry, or correction.

• Document whether the edit is an amendment, delayed entry, or correction.
• Indicate the date and author of all changes, corrections, and delayed entries.

Signatures

Legible dates, times, signatures, and credentials are required from each person (physicians, scribes, residents, nurses, etc.) who updates, reviews, and/or approves the medical record. Signatures are also required for the addition of any other pertinent information to ensure the validity of the data.

In addition, signatures must include the credentials of the performing provider. Hard-copy records must be signed (electronic signature is also acceptable) on each page by the person providing the service.

Audits

For audit purposes, ensure all required documentation is sent in by the request date and ensure the EHR software is identified.

4.7 Documentation Requirements for All Providers

All providers are required to comply with the following requirements and include the information below, as applicable, in a member’s medical records in order to support a claim for reimbursement of services.

Failure to comply with the requirements and provide the requested information may result in a denial of authorization or reimbursement for services.

Confidentiality

Medical records must be stored and maintained to fully protect the confidentiality, integrity, and safety of the member’s information.

Highmark Blue Cross Blue Shield (WNY) and Highmark Blue Shield (NENY) will preserve the confidentiality of the member's health and medical records consistent with the requirements of applicable New York State and federal law.

Medical Record Orgnization

Sections within the medical record must be organized in a consistent manner.

• All entries are legible.
• All entries are dated and timed.
• All entries must be signed or initialed by the author, with his/her title, credentials, and specialty.
• Member identifiers must be included on every page of documentation.
• All member encounters, including telephone, fax, and electronic message exchanges, are documented.

Medical History

The initial physical examination and the member’s medical history are to be recorded at the initial visit for new members. For members younger than six years old, medical record birth history must be included in the child’s medical records.

Prior medical history is documented to include any serious accidents, operations, and illnesses. In addition, family medical history is to be included in the medical record. 

Medications,Allergies,and Problems

The following must be documented prominently in the member’s medical record and updated as necessary:

• Medications currently taken and all newly prescribed medications
• Allergies and/or adverse reactions; or display “None” or “NKA” if no allergies are known
• Current and updated problem list

FDA Label Restrictions

Medical records must include documentation of weight and date of birth for prescribed medications as required by the Food and Drug Administration (FDA).

Member Encounters

For all member encounters, including telephone, fax, and electronic message exchanges, ensure that the following are clearly documented:

• Member’s chief complaint or purpose for each visit/encounter
• Clinical assessment and/or physical findings (ensure working diagnoses are consistent with these findings)
• Treatment plans and goals (ensure treatment plans are consistent with the recorded diagnosis code/s)
• Any unresolved problems from prior visits are addressed
• Follow-up instructions and necessary follow-up appointments

Treatment Options

All treatment options, conservative or alternative, are to be documented in the member’s medical record as required by Highmark Medical Policies.

Coordination of Care

Primary care physicians and specialists, including medical, surgical, and behavioral health, must communicate with one another. The exchange of information in an effective, timely, and confidential manner promotes appropriate diagnosis and treatment.

The coordination of care between primary care and specialty care providers or other practitioners is to be documented within the member’s medical record. 

Coordintion of Care Timefrmes

Time frames for this information exchange shall be within 30 calendar days of initial assessment; annually if concurrent care continues for more than 12 months, or more frequently if the member's clinical condition or treatment changes significantly and within 7 calendar days of medication change. The guidelines are supported by New York State Mental Health Law, New York State Public Health Law, Centers for Medicare & Medicaid Services (CMS) standards, and the National Committee for Quality Assurance (NCQA) Standards for Accreditation and HIPAA regulations.

Diagnostic Testing and Results

When services are provided by an external provider (e.g., radiologists, labs, referrals, consultations), the documentation they provide, including follow-up letters, are to be included in the member’s medical record.

Laboratory and diagnostic testing results must be signed by the practitioner to acknowledge that they have been reviewed. Review of diagnostic services must include the CPT codes of the diagnostic test(s) reviewed.

In addition, the documentation must confirm that the member was notified of diagnostic testing/laboratory results and the practitioner’s follow-up recommendations.

Time-Based Codes

Start and stop times and total time must be documented within the medical record when time is a required factor for reporting services.

Examples include, but are not limited to: anesthesia services, physical medicine services, screening services, prolonged services, observation services, critical care, discharge day, etc.

NOC CPT/HCPCS Codes

When a Not Otherwise Classified (NOC) CPT or Healthcare Common Procedure Coding System (HCPCS) code is billed:

• The service provided cannot have an exclusive CPT or HCPCS code, which defines the service rendered.
• A detailed description of the service or item provided must be included within the medical record.

All Codes on Claim Must Be Substantiated

All CPT, HCPCS, and ICD-10 codes reported on the claim must be substantiated within the member’s medical record. 

Amending the Medical Record

If it is necessary to amend a medical record, the original documentation should not be deleted. Retain and clearly identify all original content.

Any edits to the medical record must be clearly and permanently identified as such — as an amendment, delayed entry, or correction.

• Document whether the edit is an amendment, delayed entry, or correction.
• Indicate the date and author of all changes, corrections, and delayed entries.

4.7 Additional Requirements to Support E/MService

Coding Guidelines for E/M Services

As of Jan. 1, 2023, all Evaluation and Management services are now selected and scored based on medical decision-making (MDM) or time. Since January 2021, this change has been in effect for New Patient or Other Outpatient Services, and Established Patient or Other Outpatient Services.

Please access the Highmark Provider Resource Center's (PRC's) Documentation Guidelines for Evaluation and Management Services page, which provides guidance based on the date of service as well as the type of E/M service rendered. Auditor’s Scoring Worksheets utilized by Highmark are also available on this PRC page.

All services performed and the diagnosis(es) related to the visit must be documented in the member’s medical record.

Seperately Billed E/M Services

Separately billed E/M services following a procedure within a global surgical period must be supported in the member’s medical record.

Critieria That Must Be Documented

To ensure accuracy of diagnosis coding, the following criteria, as applicable to the visit, must be documented in the medical record:

• Laterality (left vs. right)
• Specific location of injury, pain, or disease
• Condition status (acute, chronic, chronic intractable, recurrent, controlled, uncontrolled, etc.)
• Date of occurrence of injury or symptoms
• Fracture type (e.g., open or closed, displaced or non-displaced)
• Stage of condition (e.g., decubitus ulcer stage)
• Weeks/trimester of pregnancy
• Congenital conditions
• Illness phase (e.g., dysphagia, pharyngeal phase)
• Encounter status (initial, subsequent, sequela)

This list is not an all-inclusive list; additional criteria may be necessary based on the reason for the visit.

4.7 Hospital/Facility Services

This section provides medical records documentation guidelines for services provided to members at a hospital or other facility as an inpatient, outpatient, or for emergency department care.

Hospital Medical Record

Documentation in the member’s hospital medical record for inpatient, outpatient, and emergency department visits must include the intake of the member’s history and physicals performed at the time of admission or visit.

The medical record should also include, but is not limited to, the following as applicable:

• Physician orders
• Provider’s progress notes
• Consultative physician notes and records
• Laboratory and diagnostic imaging
• Medications ordered and administered
• Immunization records
• Diagnosis codes consistent with laboratory or diagnostic services
• Critical or preventable serious adverse events (PSAE)
• Documentation of restraint usage
• Risk of treatment outcomes
• Member responsibility of services (e.g., Notice of Denial of Medical Coverage)
• Authorization requests such as, but not limited to, Availity® with information to justify admission
• Referrals to other providers
• Reason(s) why a service was discontinued or not started

Attending Physician's Progress Notes

Countersignatures by the attending physician of another physician’s orders or notes are not acceptable documentation of the attending physician’s services. A countersignature must be supplemented by the attending physician’s own progress notes.

Visit on Day of Discharge

When a claim for a hospital visit is billed on the same day as discharge, inpatient progress notes must support the reason for the visit.

Discharge Summary

The hospital discharge summary must contain the following:

• Reason for hospitalization
• Significant findings
• Procedures
• Treatments provided
• Member discharge condition
• Discharge orders
• Member education
• Discharge planning notes, including all options and/or facilities discussed with member and/or caregivers
• A written plan of care that is multi-disciplinary and is updated throughout continuum of care

Acute Care Transfers

If an acute care transfer, the rationale for the transfer must include:

• Name of facility/hospital
• Arrangements to facilitate transfer
• MD orders and updates for actual services rendered with time and dates for all inpatient and/or observation stays
• A written plan of care that is multi-disciplinary and updated throughout the continuum of care

Post-Acute Provider Referrals

Documentation for post-acute provider referrals must include MD orders and updates for actual services rendered. The MD’s orders must include time and dates for all inpatient and/or observation stays.

In addition, a written multi-disciplinary plan of care must be included and updated throughout the continuum of care.

Consultations

Requests for consultations must be documented within the member’s medical record. Consultations must be ordered and documented by the attending physician.

The consultation reports must be dictated and typed or handwritten, and they must contain the signature of the physician who performed and reported the consultation.

Services Renderd By Hospital Interns and Residents

Services rendered by interns, residents, or any other hospital/facility employee under the supervision of the attending physician may be reported by the attending physician. The care must be documented and signed by the attending physician in the progress notes, or other pertinent records, reflecting the level of medically necessary care.

Surgical Procedures

The medical record must contain all relevant information related to performing the surgical procedure, including but not limited to:

• Pre- and post-operative diagnosis(es) codes
• Implant/device make and model numbers
• Comprehensive list of procedure(s) performed
• Any techniques used to perform the procedure(s)

The performing physician’s name and all assistants’ names are to be recorded in the operative report. When a procedure(s) requires the services of two surgeons or a surgical team, documentation must clearly establish that each surgeon performed distinct and separate components in a team fashion.

The operative report must indicate the name of the anesthesiologist(s), certified registered nurse anesthetist(s) (CRNAs), and/or anesthetists who performed the anesthesia services.

Please refer to Highmark’s medical policies and reimbursement policies for more information. Highmark Medical Policy and Reimbursement Policy are both available on the Provider Resource Center.

Global Obstertical/Surgical Care

When a global service is reported, all pre- and post-operative/obstetrical care must be recorded in the member’s medical record.

Minor surgical procedures can be described in the progress/office notes and must be signed by the provider reporting the service.

Evidence of conservative measures taken should be noted, if applicable.

Anesthesia

The operative and anesthesia reports both must indicate the name of the anesthesiologist(s), CRNA(s), and/or anesthetists who performed the anesthesia services.

Start and stop times and number of units provided must be clearly documented.

Pre-and post-operative evaluations or other encounters with the member must be documented in the medical record. This is important when monitoring members who are in active labor or who post-operatively require additional anesthesia services.

When an anesthesiologist is supervising one or more anesthetists, the supervising physician’s presence and interventions must be recorded on the anesthesia record.

4.7 Ancillary Services

Ambulance

When transporting a Highmark member by ambulance, the following information must be documented and maintained in the member’s medical records:

• Member identifying information (name, Member ID, address)
• Date of service
• Point of origin/destination
• Total mileage
• Beneficiary or authorized representative signature
• Records from hospital/facility noting need for ambulance and medical necessity of transport
• Legible documentation signed by the primary attendant which includes, but is not limited to, a detailed trip sheet

If the member was transported beyond the closest facility, the reason for doing so must be contained in the medical record. In addition, the reason for transport by air ambulance instead of ground ambulance must be documented.

For additional information about ambulance services, please see Highmark Medical Policy. Medical Policy can be accessed on the Provider Resource Center by selecting Policies & Programs.

Diagnostic X-Rays and/or X-Ray Reports

Relevant and/or current records from the prescribing physician's office (e.g., office notes, history and physical, labs, etc.) can serve as supporting documentation of medical necessity for the service provided by a radiology provider.

The radiology provider must also document the following in the member’s medical record:

• Member name, Member ID, date of service
• Name of provider performing and interpreting the study
• Clear directional markers
• Specific description and diagnosis of X-ray findings
• Radiology reports for all services billed
• Overall treatment plan

When billing for travel allowance, documentation pertaining to travel expenses should also be included.

Dialysis

For dialysis services, the member’s medical record should include the member’s name, Member ID, and the date of service.

In addition, the records should include the following:

• Dialysis Flow Sheets
• Medication Record(s) 

Hospice

For hospice care, the documentation must include the following:

• The date the plan of care is established, which must occur prior to the member beginning hospice
• The date the hospice plan is initiated

4.7 Psychiatric Care, Psychotherapy, and Counseling

When psychiatric care, psychotherapy, and counseling services are provided, medical records documentation must include the requirements identified below.

Note: Psychotherapy notes should not be included in the medical records.

Date of Service and Provider Information

The date of service must appear prominently within the member’s medical record. The documentation must include the identity and legible signature of the person administering the service on that date. The provider’s certification(s) must also be documented. If applicable, the referral source must be indicated.

History

The member’s psychiatric hospitalizations and associated diagnosis(es) must be included in the medical records along with the treatment obtained and the results of each hospitalization.

In addition, a family psychiatric history, including any hospitalizations and associated diagnosis(es) codes, should also be included. Family history should also include successes with specific medications.

Observations and Type of Therapy

Observations of the member during the intake should be noted in the medical records. The type of therapy must be contained in the medical records for each session, along with content of the session and the therapeutic techniques and approaches used.

For interactive therapy, the member record must indicate the adaptations utilized in the session and the rationale for using a specific technique.

In addition, an assessment of the member’s ability to adhere to the treatment plan, as well as any treatment failures, should also be documented.

The time spent during an encounter with the member, informant, and/or the family must be legibly documented in the member’s medical records. Also, start/stop times must be documented within the medical records for all time-based codes.

Diagnoses

The diagnosis(es) must be clearly documented and the clinical presentation, which supports the diagnosis, noted.

Documentation supporting a multiaxial diagnosis must be included, if applicable. 

Medications

Any medications that the member is currently taking and all newly prescribed medications must be documented.

If there are any changes in medications or an adjustment in dosage of a medication already prescribed, the rationale for the change or adjustment needs to be clearly documented.

Progress and Follow-up

Note(s) indicating the member’s status and/or progress must be contained within the medical records documentation. In addition, follow-up instructions provided during the encounter must be included.

When E/M is Provided

When evaluation and management (E/M) is provided:

• Providers are to clearly separate and document the time spent for the E/M service and time spent for psychiatric, psychotherapy, and/or counseling services.
• E/M documentation guidelines apply as outlined in the E/M section of this Unit.
• The psychotherapy service must be “significant and separately identifiable.”

When psychotherapy is performed in addition to an E/M, the level of the E/M chosen must reflect the work performed and not the amount of time spent providing counseling and coordination of care.

4.7 Opioid Addiction Management

Controlled Substance Programs

Prior to dispensation of a controlled substance, dispensing providers are required to enroll or query the member in a controlled substance program for their respective service area. The enrollment must be documented in the member’s medical record.

Click on the appropriate link below to access the login page for the program for the member’s service area:

• Pennsylvania: Prescription Drug Monitoring Program (PDMP) at: https://pdmp.health.pa.gov/PDMPSystemApp/
• West Virginia: Controlled Substance Automated Prescription Program (CSAPP) at:https://www.csappwv.com/Account/Login.aspx?ReturnUrl=%2f
• Delaware: Delaware Prescription Monitoring Program (DPMP) at: https://dpr.delaware.gov/boards/pmp/
• New York: Office of Addiction Services and Supports at:
  • https://oasas.ny.gov/
  • https://commerce.health.state.ny.us

4.7 Diagnostic and Therapeutic Testing

When tests are performed, all reasons for the testing as well as test results/findings must be documented in the member record and signed by the ordering physician. This applies to laboratory, pathology, radiology, cardiology, and other ancillary or machine testing services.

Medical Record Documentaion

All diagnostic and therapeutic services for which a member was referred by a practitioner must be maintained in the member’s medical record records. This includes, but is not limited to:

• Home health nursing reports
• Specialty physician reports
• Hospital discharge reports
• Physical therapy reports
• All computer-generated test data results

For diagnostic testing, including laboratory and radiology, the ordering provider must maintain a copy of the request as part of the member’s permanent medical record. Additionally, the performing provider must also have a copy of the request on file in the member’s medical records.

Highmark does not permit standing orders for diagnostic testing.

Testing Interpretation

When a testing interpretation code is used, the medical record must contain a documented report signed by the physician who reported the service.

Travel Expenses

Travel expenses may be billed for some diagnostic services. Documentation pertaining to all travel expenses must be included in the member’s medical records.

4.7 Therapy Services

This section provides medical records documentation guidelines for therapy services, including: physical therapy; occupational therapy; speech therapy; chiropractic care; and acupuncture.

Requirements

The following items must be documented within the member’s medical record when treatment, manipulation, or therapy is provided:

• Member name
• Member ID number
• Date of service
• Member’s complaint
• Diagnostic studies and results
• Results of previous treatments
• Planned treatments and/or diagnostic studies

A clear description of the type of treatment provided, including the body region(s) treated, must be included in the documentation. In addition, an assessment or physical findings to support the therapeutic treatment or manipulation provided must also be included.

Associated updates to the treatment plan based on changes in the member’s condition must be noted. The medical records documentation should also include a post-treatment evaluation of the member’s response to the treatment or manipulation.

Physical Exams

When physical exams are performed, document the exams separately from the therapy or manipulation and indicate whether the exam is one of the following:

• Initial examination of a new member or condition;
  
• Re-examination of a new member within an episode of care to assess member progress, current clinical status, and determine the need for further medically necessary therapeutic level of care; or
• Acute exacerbation of symptoms or significant changes in the member’s condition, which are distinctly different indications from original treatment plan.

4.7 Durable Medical Equipment, Prosthetics, Orthotics, & Supplies

Highmark-contracted providers are strongly encouraged to refer members to providers participating in the member’s network. This includes referrals for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Reasons for referrals to out-of-network providers should be documented in the medical record.

Highmark Medical Policy

Providers are reminded to refer to the pertinent Highmark Medical Policies when referring members for DMEPOS or submitting claims for DMEPOS.

BOTH the referring physician and the DMEPOS supplier are to comply with Highmark Medical Policies (e.g., the supplier should ensure that the referring physician’s order is appropriately completed by the physician).

Dispensing Prescriptions

When dispensing prescriptions, the following requirements must be met:

• Must comply with all state prescribing and/or other laws.
• A copy of the physician order must be maintained in the medical record and contain a description of the item to be dispensed.
• The supplier may write the Detailed Written Order (DWO) or Written Order Prior to Delivery (WOPD), however, the prescribing physician must review, sign, and date prior to delivery/billing of services.
• Prescription must be dated prior to delivery date.
• Length of time item is indicated for use and updated every six months.
• Standing orders are not permitted and should be written specific to the member's condition, unless otherwise stated in relevant medical policy.

Prescriber

The ordering physician must document the member’s medical record, at a minimum, with the information below. Additional policy requirements may apply for certain DMEPOS.

• Description of DMEPOS prescribed
• Length of time DMEPOS is indicated for use and updated every six months
• Documentation to support why item continues to remain reasonable and customary for ongoing supplies
• Date of face-to-face examination
• Date and results of trial period when required by Medical Policy
• A copy of the prescribing physician’s order, including NPI
• Indication of laterality
• Risks and benefits of use

Supplier

The DMEPOS supplier’s documentation must contain, at a minimum, the information below for all billed DMEPOS. Additional policy requirements may apply for certain DMEPOS.

• Description of DMEPOS prescribed
• Copy of the physician’s written order
• Indication of laterality
• Indication of trial period, if required (see additional information below)
• Documentation referencing the actual DME dispensed; the packing slip is to include the following information:
  • Member’s name
  • Description of the DMEPOS or the full HCPCS description code
  • Quantity
  • Brand name of item
  • Model and serial numbers
  • Date dispensed

Manufacturer Order Forms

If a prescribing provider or a supplier orders from a manufacturer for a specific type of DMEPOS, the manufacturer order form must be included with the medical records and complete with all pertinent patient information:

• Patient name, date of birth, address, date of order, laterality of prosthetic/orthotic ordered;
• All pertinent practitioner information:
  • Name, credentials, address, facility (if applicable); and modifications/customizations to be clearly documented and detailed related to item ordered.

Customization and Modifications

• Documentation within the medical records of the clinician’s and/or DME, prosthetic, or orthotic fitter’s notes to list all modifications made based on the member’s condition.
• Documentation within the medical records of the clinician’s and/or DME, prosthetic, orthotic fitter’s notes is required to state how the DME, prosthetic, or orthotic was customized to meet member need as indicated by the prescriber’s order.

Supplier’s Proof of Delivery

Proof of delivery documentation must be maintained in the supplier’s records and include the information below:

• Member’s name
• Laterality, where applicable
• Detailed description to sufficiently identify the item(s) being delivered
• Quantity delivered
• Delivery date or shipping date if a delivery service is used (will be the official date of service for the claim)

The member or the member’s representative (e.g., relative, neighbor, nursing home, etc.), who does not have a financial interest in the company supplying the DMEPOS, must sign to indicate the DMEPOS was received.

The member’s medical record must include the printed name and signature of the member or the member’s designated recipient. If the recipient is someone other than the member, the designated recipient’s relationship to the member must also be noted.

Trial Periods

Please note that DMEPOS suppliers are NOT permitted to have providers and/or members attest that a trial period has occurred. If the supplier is relying on a trial period performed by another provider, the supplier is to document the name of the provider and the dates of service when the trial period occurred.

If the supplier is unable to discern whether or not a trial period occurred, the DMEPOS supplier is required to perform a trial period prior to submitting a claim for a purchase.

Refills to the Original Order

The following apply for refills to the original order:

• Supplier is required to contact the member prior to dispensing the refill to ensure the refill is necessary and document the member requested supplies.
• Suppliers must have documentation, available upon request, to demonstrate contact with the member to ensure the refill remains reasonable and necessary, existing supplies are approaching exhaustion, and to confirm any changes/modifications to the order prior to delivery or shipment of the product.
• Contact must be made and documented within the member’s record no sooner than two weeks (14 calendar days) prior to the delivery/shipping date.
• Supplier shall deliver the DMEPOS product no sooner than 10 calendar days prior to the end of usage for the current product.
• Suppliers must not dispense a quantity of supplies exceeding the member’s expected utilization.
• Suppliers must stay attuned to changed or unusual utilization patterns; suppliers are required to contact, verify, and document any changes or unusual utilization patterns with the prescribing physician.

Additional Prosthetics Guidelines

For prosthetics, the expected member functional ability information must be clearly documented and retained in the prosthetist’s records and made available upon request.

The following information must be included within the member’s medical record for all prosthetics:

• Member name
• Member ID number
• Date of serviceMember’s past history
• Member’s current condition to support the designation of the functional level
• Member’s expected functional capabilities to support the use of modifiers K0-K4
• Amputation side (laterality) clearly and consistently identified — especially for bilateral members
• Member’s desire to use the new prosthesis, or ambulate (if for lower extremity)
• Recommendation for the new prosthesis/component(s) and rationale for decision\

Microprocessor-Controlled Prosthetics

Documentation within the member’s medical record must show functional need for the technologic or design feature of the microprocessor-controlled prosthetic (e.g., knee).

Relevant Physical Exams

Any recent physical examinations that are relevant to the member’s functional deficits and the need for a prosthetic must be documented in the member’s medical records.

The focus is to document body systems impacting the member’s functional ability and ambulatory difficulties:

• Weight and height, including recent weight gain or loss
• Cardiopulmonary examination
• Musculoskeletal examination 
• Arm and leg strength and range of motion
• Neurological examination
• GaitBalance and coordination

Replacements

If the prosthetic will be a replacement, the status of the current prosthesis/component(s) and reason for replacement must be documented.

In addition, past experience with related items [previous prosthesis/component(s)], if pertinent, should be included in the member’s medical record.

Additional Orthotics Guidelines

Relevant Physical Exams

Any recent physical examinations that are relevant to the member’s functional deficits and the need for an orthotic must be documented in the member’s medical records.

The focus is to document body systems impacting the member’s functional ability and ambulatory difficulties:

• Weight and height, including recent weight gain or loss
• Musculoskeletal examination 
• Arm and leg strength and range of motion
• Neurological examination
• Gait
• Balance and coordination

4.7 Disclaimers

The following entities, which serve the noted regions, are independent licensees of the Blue Cross Blue Shield Association: Western and Northeastern PA: Highmark Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Choice Company, Highmark Health Insurance Company, Highmark Coverage Advantage Inc., Highmark Benefits Group Inc., First Priority Health, First Priority Life or Highmark Senior Health Company. Central and Southeastern PA: Highmark Inc. d/b/a Highmark Blue Shield, Highmark Benefits Group Inc., Highmark Health Insurance Company, Highmark Choice Company or Highmark Senior Health Company. Delaware: Highmark BCBSD Inc. d/b/a Highmark Blue Cross Blue Shield. West Virginia: Highmark West Virginia Inc. d/b/a Highmark Blue Cross Blue Shield, Highmark Health Insurance Company or Highmark Senior Solutions Company. Western NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Cross Blue Shield. Northeastern NY: Highmark Western and Northeastern New York Inc. d/b/a Highmark Blue Shield.

All references to “Highmark” in this document are references to the Highmark company that is providing the member’s health benefits or health benefit administration and/or to one or more of its affiliated Blue companies.