Heed the number one warning for doctor’s orders and keep the billing department happy by thoroughly and properly reviewing all physician orders. The most frequent cause for follow-up action after an accreditation survey is failure to obtain, review, and revise physician orders. To understand why this is a widespread problem, it helps to start by defining the term “prescription” and its regulatory context.

The HME provider must comply with applicable pharmacy law, including obtaining prescriptions for any drugs dispensed. In many states where HME licensure exists, the rules are administered by the state Department of Pharmacy. Still other states require that the HME company (if not affiliated with a licensed pharmacy) obtain a “dispensing” permit to provide oxygen and other devices prescribed by physicians.

A prescription is a physician’s order for a drug and oxygen is a drug. That is why the Federal Food and Drug Administration (FDA) and state Board of Pharmacy rules extend to home care providers of oxygen. Although there is some overlap between information documented on the oxygen CMN and a prescription, the current HCFA 484.2 form is not a prescription. While you are getting the physician signature on a form to bill the oxygen, you are still potentially missing key documentation to comply with the prescription rule. Any drug order (prescription) from a doctor must have the following components: the drug name, dosage, frequency, method of administration, and duration.

For example, “amoxicillin” or “oxygen” is the drug name, and the dosage for amoxicillin might be “one 450 mg tablet” or two liters per minute for oxygen. The frequency could be “take one tablet four times per day” for the antibiotic, or “use 18 to 24 hours per day” for oxygen. For the amoxicillin tablet, the method of administration would be “by mouth,” whereas for oxygen it could be “by nasal cannula.” Duration is how long the prescription is valid to be filled (14 days for the amoxicillin, 1 year or lifetime for the oxygen).

A “detailed written order” or CMN as specified by Medicare encompasses all the qualifying, detailed reasons a customer needs a device.

Physical limitations or diagnosis codes are some of the items that typically appear in conjunction with the physician signature on the CMN used to bill for products provided by an HME company. But this CMN document is not a prescription.

The confusion began in 1997 when the government revised the oxygen CMN. Prior to this time, the CMN form prompted the physician to fill in blanks indicating the patient’s oxygen use in liters per minute and hours per day. After the revision, line 6 asks only for the doctor to “enter the patient’s highest liter flow.” It never asks the physician to indicate how many hours per day the patient should use the oxygen, nor does it ask how the oxygen should be administered (usually a nasal cannula).

Drugs are classified based on their susceptibility to abuse, ranging from medications that are rarely abused (like antifungal skin cream) up to those that have a high street value. Prescribed barbiturates and amphetamines fall into the group that are susceptible to abuse, thus they require a hard-copy written order to be handed to the pharmacist. That is, the doctor cannot just “call in” the order to a pharmacy. Fortunately, for our industry, oxygen is in the class of medications deemed not subject to abuse, so we can accept a telephone order for an extended period of months or, in some states, years.

Your CSR must get complete prescription information at the time of the telephone referral. Whoever is setting up the oxygen system cannot properly educate the patient/caregiver without this information. The next challenge is to have the doctor “authenticate” his verbal order (sign the prescription) and return it to your company. If you request that the doctor fax a prescription, you will frequently receive an inadequate prescription that reads: “oxygen, two liters with portability.”

There are several strategies for getting the complete prescription from the physician. Some providers write the information they obtained at the time of the referral in Section C of the CMN, where the supplier describes the product, HCPC codes, supplier’s charge, and Medicare allowable. That way, when the physician signs the CMN, he is also signing the prescription information. Some companies use a cover letter to accompany the CMN when it is mailed to the physician. This cover letter does not coach on how to complete the CMN, but it does detail the same qualifying information obtained by the CSR at the time of referral (blood gas level, date of test, name of test facility). This cover letter includes the complete oxygen prescription (liter flow, hours per day, method of administration), as well as any other devices that might be associated (such as if the oxygen is to be administered by nasal cannula during the day, but bled into a CPAP system at night).

The HME representative completes the entire cover letter. Once the physician signs this cover letter form and returns it with the oxygen CMN, you have a complete oxygen prescription. Use this cover letter form for all oxygen referrals, Medicare or otherwise. A complete prescription is necessary regardless of payor.

Patient Education
The next challenge is to educate patients/caregivers about their complete prescription at the setup. Be careful of state respiratory therapy laws that specify qualifications for who may perform patient education regarding prescriptions. The documentation of the prescription should be consistent on the intake form, setup paperwork, any concentrator periodic maintenance checks, and, if applicable, respiratory therapist visit notes. Follow up on any discrepancies with the written prescription to determine whether the physician changed the prescription, or the patient has been noncompliant. In either case, be sure to follow it through to resolution.

A “legend device” refers to equipment that the manufacturer has labeled “federal law prohibits dispensing without a prescription.” You will find this notice on CPAP masks, nebulizer compressors, enteral pumps, phototherapy units, ventilators, and many other pieces of equipment in your warehouse. Some of these legend devices have settings, which also must be directed, in writing, by the physician.

Some oxygen conservers may alter your doctor’s prescription from continuous oxygen to intermittent pulses of oxygen. A phone request by the doctor’s office must be followed up with a written prescription.

If you find the patient going through many portables and you want to decrease utilization, you cannot just give the patient a conserver. You must have a written order! Sometimes the physician office calls for a specific liquid oxygen device, which is available only with a conserver. If the device is ordered by name, you automatically have the order for the conserver.

Vianna Zimbel, RRT, is the founder of Vianna Zimbel Consulting, Glastonbury, Conn. She can be reached via email: vzimbel@aol.com.