Applicable for Dates of Service Prior to January 1, 2020.

42 CFR 410.38(g) contains provisions that are applicable to certain specified DMEPOS items. CMS provides a list of the specified items, which is periodically updated, and located on the CMS website.

These items require an in-person, face-to-face interaction between the beneficiary and their treating physician/practitioner prior to prescribing the item. This face-to-face requirement includes examinations conducted via the CMS-approved use of telehealth examinations (as described in the CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15 and CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12).

This face-to-face evaluation must specifically document that the beneficiary was evaluated and/or treated for a condition that supports the need for the DME item(s) ordered. A dispensing order is not sufficient to provide these items. A 5EO must be received prior to delivery. Refer to the applicable LCD-related Policy Article NON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULES section for information about these statutory requirements.

Documentation Types

• ACA Face-to-Face - A practitioner (MD, DO, DPM, PA, NP, CNS) has had a F2F examination with a beneficiary within the six (6) months prior to the written order for certain DME items.
• ACA 5EO - For some items to be covered by Medicare, a written order is required to be in the supplier's file prior to delivery of the specified item(s).

ACA Items

This list is subject to CMS annual review and may change as necessary.

Resources

• ACA Face-to-Face Requirements and CERT Enforcement
• CMS Face-to-Face Encounter Requirement for Certain Durable Medical Equipment
• CMS IOM, Publication 100-08, Medicare Program Integrity Manual, Chapter 3, Section 3.3.2.5
• CMS Medicare Learning Network (MLN) Matters (MM)8304