In CMS-1713-F, the final rule that replaced detailed written orders (DWOs) with standard written orders (SWOs), CMS eliminated the requirement to document frequency. Despite the change, DME MACs and auditing contractors continued to invalidate non-specific orders with “PRN” or “as-needed” instructions, relying on old habits and outdated language in the Program Integrity Manual (PIM).
To promote consistency with the revised SWO requirements, CMS updated section 5.11 of the Program Integrity Manual (PIM) and removed conflicting language that stated “PRN” and “as-needed” were not acceptable frequencies for SWOs. The revised PIM language now reads:
“If replacement supplies are needed for the therapeutic use of purchased DMEPOS, the treating practitioner must specify on the standard written order, or on the CMN, the type of supplies needed, in such a manner that the supplier may calculate the necessary disbursement and assess the continued need for refill with the beneficiary. DME MACs, UPICs, and other contractors evaluate supply utilization information as part of their medical necessity and coverage determinations for DMEPOS.”
On the surface, it appears CMS relaxed an antiquated policy. However, the agency stopped well-short of sanctioning non-specific frequencies. The change request states that, alone, the words “PRN” or “as needed” do not provide sufficient information to allow calculation of quantity, which remains a required SWO element. CMS goes on to instruct auditors that medical documentation outside the SWO must objectively support quantities ordered by a doctor and filled by a supplier. As such, suppliers should remain guarded when it comes to non-specific order quantities.
After establishing a baseline, CMS instructs auditing contractors to refrain from a too-literal application of policy when it comes to quantity calculations. Even if the doctor does not spell everything out word-for-word, CMS expects contractors to use other readily available variables, like dosing amounts and potential frequency, to calculate quantity.
CMS also instructs contractors to assume the beneficiary will use the medication at the maximum amount prescribed so long as it does not exceed limits in the local coverage determination. For example, if an order states “Albuterol 0.83%/3ml vial every 6-hours PRN,” suppliers and auditors can determine the beneficiary should receive 120-unit dose vials. So long as coverage requirements are met, auditing contractors should infer this order supports the maximum potential quantity of 120 vials.
Upon receipt of a PRN order, suppliers should review the records and ensure a reasonable person can fill in the quantity blanks with available information in the record. Doing so should spare suppliers from premature SWO rejection and frivolous quantity denials.
SOURCE LINKS
https://www.cms.gov/files/document/r10492pi.pdf
https://www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24063.pdf
To promote consistency with the revised SWO requirements, CMS updated section 5.11 of the Program Integrity Manual (PIM) and removed conflicting language that stated “PRN” and “as-needed” were not acceptable frequencies for SWOs. The revised PIM language now reads:
“If replacement supplies are needed for the therapeutic use of purchased DMEPOS, the treating practitioner must specify on the standard written order, or on the CMN, the type of supplies needed, in such a manner that the supplier may calculate the necessary disbursement and assess the continued need for refill with the beneficiary. DME MACs, UPICs, and other contractors evaluate supply utilization information as part of their medical necessity and coverage determinations for DMEPOS.”
On the surface, it appears CMS relaxed an antiquated policy. However, the agency stopped well-short of sanctioning non-specific frequencies. The change request states that, alone, the words “PRN” or “as needed” do not provide sufficient information to allow calculation of quantity, which remains a required SWO element. CMS goes on to instruct auditors that medical documentation outside the SWO must objectively support quantities ordered by a doctor and filled by a supplier. As such, suppliers should remain guarded when it comes to non-specific order quantities.
After establishing a baseline, CMS instructs auditing contractors to refrain from a too-literal application of policy when it comes to quantity calculations. Even if the doctor does not spell everything out word-for-word, CMS expects contractors to use other readily available variables, like dosing amounts and potential frequency, to calculate quantity.
CMS also instructs contractors to assume the beneficiary will use the medication at the maximum amount prescribed so long as it does not exceed limits in the local coverage determination. For example, if an order states “Albuterol 0.83%/3ml vial every 6-hours PRN,” suppliers and auditors can determine the beneficiary should receive 120-unit dose vials. So long as coverage requirements are met, auditing contractors should infer this order supports the maximum potential quantity of 120 vials.
Upon receipt of a PRN order, suppliers should review the records and ensure a reasonable person can fill in the quantity blanks with available information in the record. Doing so should spare suppliers from premature SWO rejection and frivolous quantity denials.
SOURCE LINKS
https://www.cms.gov/files/document/r10492pi.pdf
https://www.govinfo.gov/content/pkg/FR-2019-11-08/pdf/2019-24063.pdf