Article Detail - JD DME

An invalid face-to-face examination completion date provided on the 7-Element Order is one of the most common reasons for denial, or non-affirmation, of Prior Authorization (PA) reviews and medical record reviews for Power Mobility Devices (PMD). This article intends to clarify the requirements as defined by the Local Coverage Determination (LCD) and Policy Article for PMD (L33789).

What date should be reported on the PMD 7-element order for the face-to-face (F2F) examination completion?

The PMD F2F examination has two components. These components are:

1. Decision component - An in-person visit between the beneficiary and the ordering physician/practitioner to document the decision to order a PMD; and,
2. Medical evaluation component - A medical examination to document the beneficiary's mobility limitations and functional condition.

Both components are required and must be documented in the prescribing physician/practitioner's medical records.

Several possible scenarios can affect the determination of the correct completion of the F2F examination.

F2F Scenarios

Physician/practitioner only involvement

• The ordering physician/practitioner completes the entire F2F examination (both #1 & #2 above) during the initial, in-person encounter with the beneficiary. If this is the case, the date of the F2F examination is the date of that in-person encounter.
• The ordering physician/practitioner has an initial in-person encounter with the beneficiary (#1 above) but does not complete the medical evaluation component (#2 above) of the F2F examination at this initial visit. At a subsequent visit with the ordering physician/practitioner, the medical evaluation component is completed. In this situation, the date of the F2F examination is the date of the subsequent in-person encounter when the medical evaluation is completed.

Licensed/certified medical professional (LCMP) included in evaluation

• The ordering physician/practitioner completes the decision component (#1 above) of the F2F examination at the initial in-person encounter with the beneficiary. The beneficiary is referred to another licensed/certified medical professional (LCMP), such as an Occupational Therapist (OT) or Physical Therapist (PT), who has experience and training in mobility evaluations to perform all or a portion of the medical evaluation component (#2 above) of the F2F examination. The physician/practitioner must indicate concurrence or any disagreement with the information in the written evaluation, sign and date the document. The F2F date listed on the 7-element order is the date the physician/practitioner signed, dated and indicated concurrence or disagreement with the LCMP evaluation.
• The ordering physician/practitioner refers the beneficiary to an LCMP prior to the in-person encounter (#1 above) with the beneficiary. Once the physician/practitioner has received and reviewed (stated concurrence, signed, and dated) the written report of the LCMP medical examination (#2 above), the physician/practitioner must see the beneficiary and complete the decision component (#1 above). In this scenario, the date of the F2F examination reported on the 7-element order would be the date of the in-person encounter between the physician/practitioner and beneficiary.
• The F2F examination is performed and completed during an inpatient hospital or nursing home stay, the date of the F2F examination reported on the 7-element order is either: 1) the date that both components 1 and 2 above are completed; or, 2) the date of discharge.

Amendment or correction scenarios

• The F2F examination has been completed, but the physician/practitioner later identifies that there is information not properly documented in the medical record about the beneficiary which is necessary to support coverage criteria for a PMD. If the physician/practitioner provides an amendment, correction or addenda to the F2F examination with information that arose from the previously performed F2F evaluation (both #1 & #2 above), the F2F examination date does not change on the 7-element order. The amendment, correction or addenda to the F2F evaluation should appear in the beneficiary's medical record.
• The F2F examination has been completed, but the physician/practitioner later identifies that there is information that was not addressed during the F2F examination (both #1 & #2 above) which is necessary to support coverage criteria for a PMD. The physician/practitioner must provide this new information in the medical record but since this was not a part of the original F2F, this does require a new in-person visit for the patient with the physician/practitioner. This new F2F visit date becomes the F2F date on the 7-element order.

If the date of the F2F examination is entered incorrectly or if any other information on the 7-element order must be corrected, it is recommended the supplier request that the physician/practitioner who completed the original 7-element order complete a new 7-element order. However, if a new 7-element order cannot be obtained, a corrected 7-element order is acceptable only when properly corrected/amended by the physician/practitioner who originally signed it.

Additional Resources

• CMS Medicare Program Integrity Manual 100-08, chapter 3, section 3.3.2.3 for information on amendments, corrections and delayed entries in medical documentation.
• Information on how to change a 7-element order can be found in the Noridian article, Changing a 7-Element-Order for a Power Mobility Device (Note: This page has been removed).
• PMD coverage and documentation requirements in the PMD Local Coverage Determination (LCD) and Policy Article L33789/A52498.