DME Pharmacy

Fostering Good Documentation Practices

Accreditation helps DME pharmacies put the right documentation policies and procedures in place.

To sell Medicare reimbursable DME products, pharmacies need to be accredited unless they have been in the DME business long enough to be grandfathered in. Accreditation helps pharmacies providing DME products to construct excellent documentation practices that help minimize their exposure to audits.

Sandra Canally, President of The Compliance Team, a healthcare accreditation organization, offers these documentation tips for pharmacies serving Medicare-funded patients. But beware — pharmacies must understand their own state requirements for DME products. Canally suggested using the National Supplier Clearinghouse Licensor Directory ( because it goes through every state and every item requirement.

  • Get any type of licensor or certification that’s required to sell DME products. Research what the billing criteria is through the local coverage determination (LCD). This will tell you if you need a license or a certification for that type of product.
  • Document employee training on products requiring it. For example, if you are carrying diabetic shoes, you will need patient instruction and fitting documentation, which is part of what any auditor would look at.
  • Collect documentation that shows the patient’s ailment. For example, if selling diabetic shoes, you should collect and document that the patient is in fact a diabetic.

Another product carried extensively by pharmacies is the nebulizer because the pharmacies carry the drugs used with it, says Canally. The nebulizer is a respiratory item so the pharmacy must have documented follow-up and access with 24/7 capability to respond if somebody’s nebulizer fails.

Further, nebulizers can be a rental or purchase item. If it’s a rental item, when it comes back to the pharmacy, there needs to be documentation of cleaning, testing, etc.

Mary Ellen Conway, president of consulting firm Capital Healthcare Group LLC., offers these documentation tips:

  • Don’t use a yellow highlighter because when the audit company gets your record, they scan it to create an electronic file. A yellow highlighter may end up blocking out what it is supposed to highlight.
  • Don’t submit records with post-it notes attached or write notes on medical records. Instead, place a summary narrative on the front of every record that tells the reviewer what they’re going to find, what page it is on, where it is, etc.
  • Never use white-out. Instead, initial and date all corrections regarding your own submittals. Obviously you cannot correct anything the doctor or prescriber might have written.
  • All signatures must be legible. Do not use stamped signatures. If a doctor’s or prescriber’s signature is illegible, take the time to get a signature attestation.

This article originally appeared in the DME Pharmacy December 2016 issue of HME Business.

About the Author

Joseph Duffy is a freelance writer and marketing consultant, and a regular contributor to HME Business and DME Pharmacy. He can be reached via e-mail at