Tools and Tips

• By W. David Yates, Roger E. Meiners
• Jul 01, 2006

With the 2005 elimination of Certificates of Medical Necessity (CMN) for documenting the need for manual wheelchairs, power wheelchairs and scooters; the phasing out of CMNs for hospital beds and Group III support surfaces; and the CPAP CMN removed several years ago; as well as the scuttlebutt of enteral, parenteral and IV therapy CMNs moving toward DMERC Information Forms (DIF); one might assume that we can start relaxing our scrutiny of CMNs. WRONG!

There are still quite a few CMNs left, and the DMERCs, Office of Inspector General (OIG), Benefit Integrity Unit (BIU), Federal Bureau of Investigators (FBI) and third-party auditors are not fooling around when it comes to violations of the basic rules of their completion. A single violated CMN can come with a hefty Civil Monetary Penalty of $1,000. Multiply that by the number of CMNs in your patient charts and it's easy to see why we still need to be vigilant with these wonderful little pieces of paper. With that said, there are several things that you could do (or not do) that will invalidate a CMN. This article will outline these violations so that you do not fall victim to any Civil Monetary Penalty.

Skip the White Out

Let's first talk about the use of "White Out" (or any correction fluid/tape). The discussion is very short and sweet: it cannot be used. You cannot use it, nor can the ordering physician. Anything that obscures an answer to write another answer on top of it, or to choose another answer, is not allowed. You should never send out a CMN that contains any correction fluid/tape, and if you receive one back from an ordering physician, politely inform the physician's office that it cannot be used, and start over with a new CMN.

Highlight Carefully

Highlighting is frequently used by suppliers to indicate to the ordering physician where answers need to be provided. Medicare has absolutely no problem with the use of highlighting with one exception. In Section B of many CMNs, the possible answers to a question the physician must answer are "Y" "N" or "D" respectively, for Yes, No or Does not apply. You can probably see where Medicare is going on this one. The only prohibited use of a highlighter is highlighting the answer you want the physician to circle (because you know from past experience the CMN has to be answered a certain way to qualify the patient) and then telling the physician in the cover letter to "complete all highlighted areas on the CMN." This is "leading" the physician and is not allowed. Other than this situation, anything goes with a highlighter. Color the whole page if you like! Speaking of color, my recommendation is yellow. You are free to use any color you like but occasionally blue, purple, green, pink or orange highlighting can turn black when copied, faxed or scanned. If the answer is obscured and you cannot read what is under the highlighting, it is as if the question has not been answered.

Complete Sections as Assigned

There are four sections of every CMN: A, B, C and D. Sections A and C are the supplier's responsibility and B and D are the ordering physician's responsibility. Be sure to complete A and C in their entirety, prior to obtaining the physician's signature because once it is signed, you cannot add to it. If you accidentally send out an incomplete CMN and it comes back from the physician, you may not fill in any missing information in Sections A or C. If this happens, you have two choices: send it back to the physician to add the information, or start with a fresh CMN. If you send a CMN back to a physician to complete information that you forgot to put into Sections A or C, or if the physician forgets to complete any part of Sections B or D, the physician must make the correction(s), initial and date the changes. Failure to follow this procedure can result in monies being recouped in an audit.

Section B of any CMN does not necessarily need to be completed by the ordering physician personally. (It can never be completed by you!). Anyone directly employed by the physician or any credentialed professional (a person with those cute little letters that follow their name such as RD, RN, PT, RT, PA, etc.) working under the medical direction of the physician can complete Section B for the physician. In this situation, this person must indicate their name, title and employer at the bottom of Section B. The physician must still sign and date Section D.

Section D is always signed and dated by the ordering physician. Stamped signatures are never allowed on a CMN and the handwriting (and ink color) of the signature and the date MUST match. If it is obvious to you that the doctor signed the CMN but the date was completed by someone else, it will also be obvious to an auditor — can you say "$1,000 Civil Monetary Penalty?" In addition, the physician listed in Section A must be the physician who signs the CMN. For example, Dr. Smith works for Smith & Jones, PC (two physicians in private practice together) and Dr. Smith ordered your patient's oxygen (and their name and UPIN are in Section A) but when you sent the CMN to their office, Dr. Smith was on vacation in Hawaii for two weeks. Dr. Jones sees the CMN, vaguely recognizes the patient, completes the CMN, and signs and dates the CMN. Naughty, naughty Dr. Jones! Do not accept this CMN, wait for Dr. Smith to return from vacation or fax it to his private condo in Maui (not recommended).

Fax the Back

Two last things to keep in mind about CMNs. If you turn your CMNs around with your physicians in person or by mail, be sure the front and back are on the same physical piece of paper. Secondly, if you fax your CMNs, be sure to fax the front and back of the CMN to the physician. The physician is only required to fax the front back to you and if you have multiple CMNs faxing to the same doctor, fax all the fronts and one back.

If you pay attention to these simple rules you should not run afoul of Medicare regulations and avoid Civil Monetary Penalties. Playing with incomplete or violated CMNs is like playing with a loaded gun … if things "go off," it could get really messy. Forewarned is forearmed!

This article originally appeared in the July 2006 issue of HME Business.