Glossary / Policy article
Policy article Medicare DME termPolicy article
The billing and coding article attached to an LCD, plus the DME MAC Standard Documentation Requirements article (A55426) reviewers apply alongside it.
A policy article, formally a billing and coding article, is the companion document to an LCD. When CMS moved coding and billing instructions out of LCDs, that material went into articles published in the Medicare Coverage Database with an A-number. The LCD says when an item is reasonable and necessary; the article says which HCPCS codes, modifiers, and documentation specifics apply.
For DME suppliers the most important article is A55426, Standard Documentation Requirements for All Claims Submitted to DME MACs. It sets out the Standard Written Order elements, the face-to-face and WOPD rules, medical-record standards, proof-of-delivery methods, and the 7-year retention rule, and it applies to every claim regardless of category. Each LCD also has its own article, such as A52514 for oxygen, A52517 for respiratory assist devices, and A52497 for manual wheelchair bases.
Reviewers read the LCD and the article together. Documentation gaps that sink claims, such as a missing specialty evaluation for a complex wheelchair or the rule that supplier-prepared statements do not establish medical necessity, are often stated in the article rather than the LCD.
Common questions
Is a policy article binding?
It carries the DME MACs' documentation and coding requirements, and reviewers apply it. Treat it as part of the coverage policy.
Which article should every DME biller read?
A55426. It is the baseline for every DME MAC claim and the source for most of the general checklist items in the guides on this site.
Related
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Sources: DME MAC Article A55426 — Standard Documentation Requirements · CMS: Medicare Coverage Determination Process . Definitions summarize public Medicare policy and are not legal or billing advice.
More terms
- ADR — Additional Documentation Request
- Prior authorization
- Affirmation and non-affirmation
- UTN — Unique Tracking Number
- SWO — Standard Written Order
- Face-to-face encounter
- DME MAC — Durable Medical Equipment Medicare Administrative Contractor
- Jurisdiction
- PTAN — Provider Transaction Access Number
- NPI — National Provider Identifier
- MBI — Medicare Beneficiary Identifier
- LCD — Local Coverage Determination
- NCD — National Coverage Determination
- HCPCS — Healthcare Common Procedure Coding System
- Length of need
- Prior authorization exemption
- Competitive bidding
- CMN and DIF — Certificate of Medical Necessity and DME Information Form
- Proof of delivery
- TPE — Targeted Probe and Educate
- Prepayment review