Just before COVID-19 gobbled up global attention, the MACs posted an FAQ document answering several common questions about standard written orders (SWO) established by the CY 2020 ESRD Prospective Payment System Final Rule (Final Rule). Even still, the guidance on order dates and non-essential order elements remains incomplete.
Order Date and Timeliness Remain Fuzzy
The Final Rule only requires a dated order before submission. In doing so, it provides maximum supplier flexibility to accept a verbal order, deliver product, generate the SWO, and hold the claim until the supplier receives the completed order.
The FAQs, however, introduce four different dates that may factor into SWO validation:
“Ideally it should be reflective of when the order was first communicated to the supplier, in order to support the dates of service on the claim.”
The FAQ goes on to state that, when multiple dates appear on the order, the MACs will use the earlier communication date in lieu of a later signature date. As such, the guidance suggests the order may not support the date of service if it comes before the date on the order. While the Final Rule alters longstanding policy that order dates must come before service dates, the MACs’ answers leave us uncertain that claim processing logic will adapt to the Final Rule’s intention.
We expected the MACs to instruct reviewers to verify the timeliness of order dates using the claim’s date of receipt. Surprisingly, the answers do not acknowledge submission date.
To be safe, suppliers who deliver product prior to securing a billable SWO should add a start date to the order form. Since the start date will always come before date of service and the submission date, doing so will support both the MAC interpretation and the Final Rule.
MACs Continue to Recommend Suppliers Capture Nonessential Elements
The Final Rule significantly slims down the required elements for a valid SWO, eliminating several non-essential elements like:
Frequency is no longer a required order element … but suppliers/providers are permitted to add elements that may provide clarity for issues such as LON, frequency of use, dosage form/strength, refills frequency, etc. Suppliers may also wish to consult state law or regulation since some states may have additional requirements for the elements of an order/prescription.
Doesn’t suggesting suppliers add additional items for clarity effectively make the element required?
If a claim denies for a nonessential element, the QIC or ALJ will likely apply the Final Rule regulations as intended. Unfortunately, challenging unfavorable findings in the interim is costly. Given conflicting and fuzzy guidance, suppliers are understandably wary of scaling back order forms and templates.
While we believe several of the FAQs contradict the Final Rule’s intent, it will take time to test the MACs interpretations, policies, and payment decisions. Nonetheless, we remain optimistic suppliers will see important revisions to these initial interpretations.
SOURCE LINKS
https://cgsmedicare.com/jc/help/faqs/current/swo.html
https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis
Order Date and Timeliness Remain Fuzzy
The Final Rule only requires a dated order before submission. In doing so, it provides maximum supplier flexibility to accept a verbal order, deliver product, generate the SWO, and hold the claim until the supplier receives the completed order.
The FAQs, however, introduce four different dates that may factor into SWO validation:
- Communication date (the date the referral contacts the supplier to fill an order).
- Service date (the date the supplier delivers product).
- Practitioner signature date (the date the doctor signs an order).
- Claim submission date (the date the MAC receives a claim for payment).
“Ideally it should be reflective of when the order was first communicated to the supplier, in order to support the dates of service on the claim.”
The FAQ goes on to state that, when multiple dates appear on the order, the MACs will use the earlier communication date in lieu of a later signature date. As such, the guidance suggests the order may not support the date of service if it comes before the date on the order. While the Final Rule alters longstanding policy that order dates must come before service dates, the MACs’ answers leave us uncertain that claim processing logic will adapt to the Final Rule’s intention.
We expected the MACs to instruct reviewers to verify the timeliness of order dates using the claim’s date of receipt. Surprisingly, the answers do not acknowledge submission date.
To be safe, suppliers who deliver product prior to securing a billable SWO should add a start date to the order form. Since the start date will always come before date of service and the submission date, doing so will support both the MAC interpretation and the Final Rule.
MACs Continue to Recommend Suppliers Capture Nonessential Elements
The Final Rule significantly slims down the required elements for a valid SWO, eliminating several non-essential elements like:
- Length of need (LON),
- Frequency of replacement,
- Number of refills,
- Dosage, and
- Strength.
Frequency is no longer a required order element … but suppliers/providers are permitted to add elements that may provide clarity for issues such as LON, frequency of use, dosage form/strength, refills frequency, etc. Suppliers may also wish to consult state law or regulation since some states may have additional requirements for the elements of an order/prescription.
Doesn’t suggesting suppliers add additional items for clarity effectively make the element required?
If a claim denies for a nonessential element, the QIC or ALJ will likely apply the Final Rule regulations as intended. Unfortunately, challenging unfavorable findings in the interim is costly. Given conflicting and fuzzy guidance, suppliers are understandably wary of scaling back order forms and templates.
While we believe several of the FAQs contradict the Final Rule’s intent, it will take time to test the MACs interpretations, policies, and payment decisions. Nonetheless, we remain optimistic suppliers will see important revisions to these initial interpretations.
SOURCE LINKS
https://cgsmedicare.com/jc/help/faqs/current/swo.html
https://www.federalregister.gov/documents/2019/11/08/2019-24063/medicare-program-end-stage-renal-disease-prospective-payment-system-payment-for-renal-dialysis
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