The Compliance Triple-Check.

The exact three-pass review Burst runs against every Medicare Part B supply claim before submission. Each pass has to clear before a claim moves forward: chart match, Standard Written Order & proof of delivery, and LCD coverage check. Use it as a pre-submission checklist for your own billing team.

Built for Compliance Officers Directors of Nursing CFOs Billers & Coders

Scope. This checklist covers consumable supplies billed to traditional Medicare Part B under a facility's institutional NPI for residents not in a covered Part A stay — surgical dressings, ostomy, urological, and tracheostomy supplies, plus prosthetic and orthotic devices. It does not cover Durable Medical Equipment (DME), which an SNF may not bill under its institutional NPI. Enteral nutrition is billed only under Medicare Advantage contracts, not traditional Medicare.

Before you start

Pull the resident's chart, the order, and the delivery record for the date of service you intend to bill.

Run all three passes

If any single box can't be checked, the claim does not move forward until the gap is closed.

Keep the record

Every supporting document is retained for seven years from the date of service.

Pass One

Chart Match

Confirm the resident is eligible and the medical record actually supports what was ordered. Eligibility turns first on Part A stay status.

Resident was not in a Medicare Part A-covered stay on the date of service.

Verified contemporaneously with the date of service — a retroactive payer-status determination is not sufficient. During a covered Part A stay these supplies are bundled into consolidated billing and cannot be billed separately to Part B.

42 U.S.C. § 1395yy(e) · 42 C.F.R. § 411.15(p)

For a dual-eligible resident, the supply is not already reimbursed under the Medicaid nursing-facility per diem.

Submitting a Part B claim for an item already covered by the Medicaid per diem is duplicate billing.

The contemporaneous medical record supports the type, quantity, and frequency of the item ordered.

The record may draw from the nursing facility, treating practitioners, hospitals, and other professionals involved in the resident's care. A supplier-prepared statement or attestation alone is not enough — it must be corroborated by the contemporaneous medical record.

The qualifying clinical condition for the category is documented.

For example: a qualifying wound (surgical dressings), permanent urinary incontinence (urological), or an open surgical tracheostomy expected to remain open at least three months (tracheostomy).

Pub. 100-02, Ch. 15, §§ 100 & 120

Pass Two

Standard Written Order & Proof of Delivery

Confirm the order and the delivery are both complete and on file before submission. No order, no delivery proof — no claim.

A complete Standard Written Order (SWO) is on file, communicated by the treating practitioner before the claim is submitted.

The SWO must contain: (a) beneficiary name or MBI; (b) order date; (c) a general description of the item — description, HCPCS code, or brand/model; (d) quantity, if applicable; and (e) the treating practitioner's name or NPI with an original signature. Signature and date stamps are not permitted.

CMS Policy Article A55426

For any item requiring a Written Order Prior to Delivery (WOPD), the signed order was received before the item was delivered.

Burst does not submit a claim for any WOPD item delivered without a completed order already on file.

If payment is expected to be denied, a signed Advance Beneficiary Notice (ABN) is on file before delivery.

Where denial is anticipated for medical necessity, coverage criteria, or frequency limits, a valid ABN (Form CMS-R-131) must be signed by the beneficiary or representative before delivery, with a copy retained in the claim file.

Proof of Delivery (POD) confirms the supplies were delivered to the facility and received by or on behalf of the beneficiary.

Quantities delivered and used must justify the quantity billed. A supplier or its employees may not sign as the beneficiary's designee.

42 C.F.R. § 424.57(c)(12)

For a recurring supply, a documented, individualized refill request is on file before shipment.

The beneficiary or caregiver must affirmatively confirm continued need. Automatic shipment on a pre-set schedule is not permitted. Contact may occur no sooner than 30 days before the current supply runs out, and delivery no sooner than 10 days before. Retrospective refill documentation is not acceptable.

Records retention. Every SWO, medical record, proof of delivery, and refill confirmation is retained for seven years from the date of service. 42 C.F.R. § 424.57(c)(12); Program Integrity Manual, Ch. 5, § 5.10.

Pass Three

LCD Coverage Check

Confirm the item is a permissible Part B carve-out, coded correctly, and within the category's coverage and quantity limits.

The supply is a permissible Part B carve-out — a prosthetic device or surgical dressing — and is not Durable Medical Equipment (DME).

An SNF may not bill DME under its institutional NPI; DME must be billed to the DME MAC by a separately enrolled supplier. Burst identifies and excludes DME at intake.

Pub. 100-04, Ch. 7, § 60

The HCPCS code maps to the correct revenue code and bill type.

Revenue Code 274 for prosthetic and orthotic devices; Revenue Code 623 for surgical dressings (A6000-series HCPCS); bill type 22X for Part B inpatients. Claims are submitted on the UB-04 (Form CMS-1450).

Pub. 100-04, Ch. 7, § 60.1

The claim meets the category-specific LCD requirements and sits within its quantity and frequency limits.

Each category carries its own Local Coverage Determination. Confirm the documentation and quantities against the applicable LCD below.

Category	LCD / Article	Watch-outs
Surgical dressings	L33831 A54563	Qualifying wound documented; wound evaluations updated at least monthly (weekly in a nursing facility or for heavily draining/infected wounds). Primary vs. secondary dressing change frequencies must be clinically consistent.
Ostomy supplies	L33828	Quantities within the LCD maximums for the ostomy type; excess requires documented justification. No more than a one-month supply dispensed at a time in a nursing facility.
Urological supplies	L33803 A52521	Indwelling: one catheter/month routine unless a specific clinical indication is documented. Intermittent kits (A4297/A4353) capped at 200 units/month combined. No more than a three-month supply dispensed at a time.
Tracheostomy supplies	L33832 A52492	Open surgical tracheostomy open (or expected to remain open) at least three months. Care kit A4625 is not medically necessary beyond two weeks post-op. One-month dispensing limit in a nursing facility.
Enteral nutrition	L38955	Billed only under Medicare Advantage contracts — not traditional Medicare. Under traditional Medicare it must go to the DME MAC, which falls outside Burst's billing model.

If a claim clears all three passes

It is staged for submission on the UB-04 under the facility's institutional NPI. If a later review finds that payment was received but not owed, the overpayment is reported and returned within 60 days of identification. Burst's Compliance Officer also runs quarterly audits of a random sample of Part B supply claims against all six checkpoints above.

42 U.S.C. § 1320a-7k(d) — the 60-day rule

Read the full compliance brief →

This checklist is provided by Burst Medical Billing for general educational purposes for skilled nursing facility billing teams. It summarizes federal statute, CMS manual guidance, and Local Coverage Determinations current as of the review date below, and is not legal advice. Coverage rules change; verify the current LCD and CMS guidance for your jurisdiction before submitting claims. LCD references verified against the CMS Medicare Coverage Database.