Face-to-Face and Written Order Requirements for High Cost DME - Dear Physician Letter - JA DME

Dear Physician,

For certain specified items of durable medical equipment the Affordable Care Act requires that an in-person, face-to-face examination (F2F) documenting the need for the item must have occurred sometime during the six (6) months prior to the order for and delivery of the item. The purpose of this letter is to provide a summary of these requirements.

A F2F examination meeting the requirements discussed below is required each time a new prescription for one of the specified items is required. A new prescription is required by Medicare:

• For all claims for purchases or initial rentals
• When 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
• When required by state law

These requirements are effective for all new orders (prescriptions) for the specified items created on or after July 1, 2013.

Face-To-Face Examination Requirements

The physician 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.

This face-to-face requirement includes examinations conducted via the Centers for Medicare & Medicaid Services (CMS)-approved use of telehealth examinations (as described in Chapter 15 of the Medicare Benefit Policy Manual and Chapter 12 of the Medicare Claims Processing Manual – CMS Internet-Only Manuals, Publ. 100-02 and 100-04, respectively).

For the physician 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 prescriber must provide a copy of the face-to-face examination and the prescription for the item(s) to the DMEPOS supplier before the item can be delivered.

Prescription (order) Requirements

These items require a written order prior to delivery (WOPD). A WOPD is the standard Medicare detailed written order, which must be completed and in the DMEPOS supplier's possession BEFORE the item can be delivered. The prescription (order) for the DME must meet all requirements for a WOPD and include all of the items below:

• Beneficiary's name,
• Physician's Name
• Date of the order and the start date, if start date is different from the date of the order
• Detailed description of the item
• The prescribing practitioner's National Provider Identifier (NPI),
• The signature of the ordering practitioner
• Signature date

For any of the specified items provided on a periodic basis, including drugs, the written order must include:

• Item(s) to be dispensed
• Dosage or concentration, if applicable
• Route of Administration, if applicable
• Frequency of use
• Duration of infusion, if applicable
• Quantity to be dispensed
• Number of refills, if applicable

Note that prescriptions for these specified DME items require the National Provider Identifier to be included on the prescription. Prescriptions for other DME items do not have this NPI requirement.

Date and Timing Requirements

There are specific date and timing issues:

• The date of the F2F must be on or before the date of the written order (prescription) and may be no older than 6 months prior to the prescription date.
• The date of the F2F must be on or before the date of delivery for the item(s) prescribed.
• The date of the written order must be before the date of delivery (DOS).
• The DMEPOS supplier must have documentation of both the face-to-face visit and the completed WOPD in their file prior to the delivery of these items.

This letter is intended to be a general summary. It is not intended to take the place of the law, regulations, or national and local coverage determinations. Detailed information about these requirements can be found on the CMS web site https://www.cms.gov or on the DME contractors' web site.

Sincerely,

Paul J. Hughes, MD
Medical Director, DME MAC, Jurisdiction A
NHIC, Corp.

Stacey V. Brennan, MD, FAAFP
Medical Director, DME MAC, Jurisdiction B
National Government Services

Robert D. Hoover, Jr., MD, MPH, FACP
Medical Director, DME MAC, Jurisdiction C
CGS Administrators, LLC

Eileen Moynihan, MD
Medical Director, DME MAC, Jurisdiction D
Noridian Healthcare Solutions

TABLE A: DME List of Specified Covered Items

The DME list of Specified Covered Items is as follows. The original list was at 77 FR 44798. This original list contains some codes that have been deleted or that were made not valid for Medicare (*) in the interim while some other codes have had narrative changes (**). Updates to the list will be made as CMS releases revisions. 

Refer to the Pricing, Data Analysis and Coding Contractor web site for information on coding at http://www.dmepdac.com/.