To Enrich Lives

FACE-TO-FACE AND WRITTEN ORDER REQUIREMENTS FOR CERTAIN TYPES OF DME

Revised October 2018

Dear Physician,

For certain specified items of durable medical equipment (listed on CMS’s website, https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/FacetoFaceEncounterRequirementforCertainDurableMedicalEquipment.html), as a condition of payment pursuant to 42 CFR 410.38(g), certain specified covered items of DME require:

1. An in-person, face-to-face examination with the treating practitioner (Medical Doctor (MD), Doctor of Osteopathic Medicine (DO) or Doctor of Podiatric Medicine (DPM), physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS)) and,

2. The treating practitioner must document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered the document must be in a pdf form.

3. The face-to-face examination must have occurred sometime during the six (6) months prior to the date of the order for the item.

The purpose of this letter is to provide additional details of these requirements.

Medicare rules stipulate that a face-to-face examination meeting the requirements discussed below be performed each time a new prescription (i.e., written order) for one of the specified items is written. A new prescription is required by Medicare:

• For all claims for purchases or initial rentals

• If there is a change in the order for the accessory, supply, drug, etc.

• On a regular basis (even if there is no change in the order) only if it is so specified in the documentation section of a particular medical policy

• When an item is replaced

• When there is a change in the supplier, and the new supplier is unable to obtain a copy of a valid order and documentation from the original supplier.

Prescription (order) Requirements

The statute requires a specific written order prior to delivery for the specified items of DME. The order has five (5) mandatory elements, referred to as a 5-element order (5EO).

• The 5EO must include all of the following: Read more