Provider Enrollment and Ongoing Responsibilities : Documentation

Medical Records

A dated clinician's signature must be included in all medical notes. According to Wis. Admin. Code § DHS 106.02(9)(b), a provider is required to include certain written documentation in a member's medical record.

Documentation for Disposable Medical Supplies and Durable Medical Equipment

Providers are required to prepare and maintain truthful, accurate, complete, legible, and concise documentation of the member's continuing use of the equipment, as well as documentation of all DME/DMS services as stated in Wis. Admin. Code § DHS 106.02(9)(a). A current, signed, and dated physician prescription is required for each DME/DMS for each DOS when requesting Medicaid reimbursement. Per Wis. Admin. Code § DHS 105.02(4), providers are required to maintain medical records for no less than five years from the date of reimbursement.

For DME/DMS requiring a face-to-face visit, documentation of the face-to-face visit is required. Providers are required to produce and/or submit the documentation to ForwardHealth upon request. ForwardHealth may deny or recoup payment for services that fail to meet this requirement.

The documentation of the face-to-face visit must be clearly titled and be a separate and distinct section of (or a clearly titled addendum to) the prescription and must include:

• Date of the face-to-face visit
• Name and credentials of the physician or NPP who conducted the face-to-face visit
• The clinical findings that support the member's need for the impacted DME/DMS
• Signature of the prescribing physician or NPP who conducted the face-to-face visit for impacted DME/DMS

Dates of Service

ForwardHealth defines the DOS as follows:

• The date on which the DME was dispensed to the member or the member's caregiver by the provider
• The date on which the DME was shipped or mailed to the member or the member's caregiver if the provider used a shipping service or mail order

Documentation Requirements for Date of Delivery

The billing provider's record must adhere to all of the following documentation requirements related to the date of delivery of DME.

When Dispensed Directly to the Member or the Member's Caregiver

The billing provider's record must include all of the following documentation related to the date of delivery when the provider dispenses DME to the member or the member's caregiver:

• Written confirmation of delivery of the product/service to the member, which includes the following:
• Date of delivery
• Member's printed name
• Member's acknowledgment of receipt with member's signature and date signed
• If member is not able to sign, the printed name of the person accepting delivery, that person's signature, date signed, and relationship to the member
• Brand, model, and sizes issued to the member
• Quantity dispensed

When Mailed or Shipped to the Member or the Member's Caregiver

The billing provider's record must include all of the following documentation related to the date of delivery when the provider mails or ships DME to the member or the member's caregiver:

• Written confirmation of delivery of the product/service to the member, which includes the following:
• Member's printed name
• Delivery address
• Delivery service's package identification number, supplier invoice number, or alternative method that links the supplier's delivery documents with the delivery service's records (this information should be printed out and kept on file or in the member's medical record)
• Brand, model, and sizes issued to the member
• Quantity delivered
• Date delivered

Any claim for DME that does not include complete proof of delivery from the provider may be subject to recoupment during a provider audit.

Additional Requirements for Compression Garments

Providers are required to maintain the following supporting documentation in their records for compression garments:

• Signed and dated physician prescription that includes the following:
  • Diagnosis
  • Amount of compression ordered
  • Prescribed garment
  • Body part for which the garment was prescribed
• Manufacturer's invoice for the compression garment that was provided
• Clinical information, including the following:
  • Specific documented measurements required for the garment ordered (this information may be found on the manufacturer's order form)
  • Date(s) on which measurements were taken
  • Appropriate periodic circumferential measurements, using consistent units of measurement (e.g., centimeters used at every measurement)
• Documentation submitted with a PA request
• Documentation submitted with a claim

Additional Requirements for Diabetic Shoes and Inserts

The billing provider is required to document and maintain the following information in the member's medical record:

• A physician's prescription for diabetic shoes and/or inserts
• The member's ICD diagnosis (or diagnoses) and any other co-morbid conditions that support the condition for the requested services
• The objective measurement of specific foot deformity, if applicable
• The member's height and weight
• The shoe brand, model number, and size(s)
• Medical records from the prescribing provider that support the claim
• The written report of the member's podiatry exam and results
• The member's ambulatory status and/or transfer abilities
• The member's use of any ambulation aids for mobility, if applicable
• Information regarding the member's functional daily routine (e.g., place of residence, caregiver type, and level of assistance, if applicable)
• Specific reason for the requested service, date of initial issue of the requested service to the member, or the reason for replacement and the last DOS to member, if known
• If mismatched shoes are requested, documentation of the foot size discrepancy

In addition to the above, the medical record for custom molded shoes using HCPCS procedure code A5501 (For diabetics only, fitting [including follow-up], custom preparation and supply of shoe molded from cast[s] of patient's foot [custom molded shoe], per shoe) must include the following:

• Documentation that the member has a foot deformity that cannot be accommodated by a depth shoe
• A detailed description of the nature of the severity of the deformity
• Documentation from the visit that included taking impressions, making cases, or obtaining CAD/CAM images of the member's feet in order to create models of the feet

In addition to the above, the medical record for custom molded inserts using HCPCS procedure code A5513 (For diabetics only, multiple density insert, custom molded from model of patient's foot, total contact with patient's foot, including arch, base layer minimum of 3/16 inch material of shore a 35 durometer [or higher], includes arch filler and other shaping material, custom fabricated, each) must include the following:

• A list of materials that were used
• A description of the custom fabrication process

Additional Requirements for Facial Prosthetics

ForwardHealth requires that the billing provider maintains the following documentation in the member's medical record for coverage of facial prosthetics:

• A written prescription for the facial prosthetic or repair
• Documentation of the loss or absence of facial tissue due to disease, trauma, surgery, or congenital defect
• Documentation of member visits to take impressions and make molds
• A copy of written instructions for the member regarding how to wear and care for the prosthetic
• Date-of-delivery documentation

Additional Requirements for Orthopedic or Corrective Shoes and Foot Orthotics

The billing provider's record of service for orthopedic or corrective shoes or foot orthotics must include all of the following:

• A prescription for orthopedic or corrective shoes or foot orthotics, and for all related services (modifications, repair, etc.), that meets the requirements stated in Wis. Admin. Code § DHS 107.02(2m)(b) and includes the following:
  • An ICD diagnosis that supports the medical need for the requested orthopedic or corrective shoes or foot orthotics
  • If present, an ICD diagnosis of any other co-morbid conditions of the member that support the medical need for the requested orthopedic or corrective shoes or foot orthotics
  • If present, an ICD diagnosis of the member's gross foot deformity and/or other conditions that justify the medical need for the orthopedic or corrective shoes or foot orthotics
  • The quantity to be dispensed and the length of need
  • The member's ICD diagnosis (or diagnoses) and any other co-morbid conditions that support the condition for the requested services
• If present, the objective measurement of specific foot deformity
• The member's height and weight
• The shoe brand, model number, and size(s)
• Medical records from the prescribing provider that support the PA request
• The written report of the member's podiatry exam and results
• The member's ambulatory status and/or transfer abilities
• The member's use of any ambulation aids for mobility, if applicable
• Information regarding the member's functional daily routine (e.g., place of residence, caregiver type, and level of assistance, if applicable)
• Specific reason for the requested service, date of initial issue of the requested service to the member, or the reason for replacement and the last DOS to member, if known
• If new equipment is requested to replace current items, the estimate of charges to repair the member's current equipment and/or the reason repair is not possible or cost-effective
• If mismatched shoes are requested, documentation of the foot size discrepancy
• If custom services are requested, documentation of the services or equipment that have been tried by the member and results indicating what specific medical needs of the member were not met
• A copy of the completed PA request and all records submitted for the service
• Written instruction to the member for the use and care of the items dispensed
• All information to support both PA requests and claims

Additional Requirements for Speech Generating Devices, Digitized

ForwardHealth requires that billing providers maintain the following documentation in their medical records:

• Prescription for the device
• Date-of-Delivery documentation
• A formal evaluation of the member's communication abilities by a SLP. The SLP must document and confirm all of the following:
  • The member has a severe expressive speech impairment, and alternative natural communication methods are not feasible or are inadequate for that individual's daily functional communication needs.
  • The member's speech impairment will benefit from the device.
  • The member has the prerequisite skills to utilize the devices.
  • The member possesses a treatment plan that includes a training schedule for the selected device.
  • The rational for a specific device, including how its features match the member's communication needs and skills.