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

Monday, December 3, 2018 @ 03:12 PM  posted by jbuytaert
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; and,
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:
o Beneficiary’s name
o A description of the item of DME ordered – the description can be either a general description (e.g., wheelchair or hospital bed), a HCPCS code, a HCPCS code narrative, or a brand name/model number
o Signature of the prescribing physician/practitioner
o Prescribing physician/practitioner’s National Practitioner Identifier (NPI)
o The date of the order
• The 5EO must be completed within six (6) months after the required ACA 6047 face-to-face examination; and,
• The date of the written order shall be on or before the date of delivery or date shipped if the shipping date is used as the date of service.
Face-to-face Examination Requirements
For Medicare beneficiaries, the treating practitioner must have a face-to-face examination with the beneficiary in the
six (6) months prior to the date of the written order for the specified items of DME.
For the treating practitioner prescribing a specified DME item:
• The face-to-face examination with the beneficiary must be conducted within the six (6) months prior to the
date of the prescription.
• The face-to-face examination must document that the beneficiary was evaluated and/or treated for a
condition that supports the need for the item(s) of DME ordered.
• Remember that all Medicare coverage and documentation requirements for DMEPOS also apply.
There must be sufficient medical information included in the medical record to demonstrate that the applicable
coverage criteria are met. Refer to the applicable Local Coverage Determination for information about the medical
necessity criteria for the item(s) being ordered.
The treating practitioner that conducted the face-to-face examination does not need to be the prescriber for the DME
item; however, the prescriber must:
• Verify that the in-person visit occurred within the six (6) months prior to the date of their prescription; and,
• Have documentation of the face-to-face examination that was conducted.
Upon request by the contractor, all DMEPOS suppliers must provide documentation from the qualifying face-to-face
examination and the completed 5EO. This will be obtained from you as the providing physician.
This letter is intended to be a general summary and does not take the place of the law, regulations, or national and
local coverage determinations. Detailed information about these requirements can be found on the CMS website
https://www.cms.gov or on the DME contractors’ website.

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