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ACA: Face-to-Face and Detailed Written Order

The Standard Written Order (SWO) requirements are in effect for dates of service January 1, 2020 and after.
Refer to the SWO page for the elements needed in this streamlined order.
Continue to use the instructions below for dates of service prior to January 1, 2020.

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.

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HCPCS Code Description
E0185 Gel or gel-like pressure mattress pad
E0188 Synthetic sheepskin pad
E0189 Lamb's wool sheepskin pad
E0194 Air fluidized bed
E0197 Air pressure pad for mattress standard length and width
E0198 Water pressure pad for mattress standard length and width
E0199 Dry pressure pad for mattress standard length and width
E0250 Hospital bed fixed height with any type side rails, mattress
E0251 Hospital bed fixed height with any type side tails without mattress
E0255 Hospital bed variable height with any type side rails with mattress
E0256 Hospital bed variable height with any type side rails without mattress
E0260 Hospital bed semi-electric (Head and foot adjustment) with any type side rails with mattress
E0261 Hospital bed semi-electric (head and foot adjustment ) with any type side rails without mattress
E0265 Hospital bed total electric (head, foot and height adjustments) with any type side rails with mattress
E0266 Hospital bed total electric (head, foot and height adjustments) with any type side rails without mattress
E0290 Hospital bed fixed height without rails with mattress
E0291 Hospital bed fixed height without rails without mattress
E0292 Hospital bed variable height without rail without mattress
E0293 Hospital bed variable height without rail with mattress
E0294 Hospital bed semi-electric (head and foot adjustments) without rail with mattress
E0295 Hospital bed semi-electric (head and foot adjustments) without rail without mattress
E0296 Hospital bed total electric (head, foot and height adjustments) without rail with mattress
E0297 Hospital bed total electric (head, foot and height adjustments) without rail without mattress
E0300 Pediatric crib, hospital grade, fully enclosed
E0301 Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, without mattress
E0302 Hospital bed, Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of tail, without mattress
E0303 Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, with mattress
E0304 Hospital bed heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, with mattress
E0424 Stationary compressed gas Oxygen System rental: includes contents, regulator, nebulizer, cannula or mask and tubing
E0431 Portable gaseous oxygen system rental includes portable container, regulator, flowmeter, humidifier, cannula or mask, an tubing
E0433 Portable liquid oxygen system
E0434 Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, cannula or mask, and tubing
E0439 Stationary liquid oxygen system rental; includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing
E0441 Oxygen contents, gaseous (1 months supply)
E0442 Oxygen contents, liquid (1 months supply)
E0443 Portable Oxygen contents, gas (1 months supply)
E0444 Portable oxygen contents, liquid (1 months supply)
E0450 Volume control ventilator without pressure support used with invasive interface
E0460 Negative pressure ventilator portable or stationary
E0461 Volume control ventilator without pressure support node for a noninvasive interface
E0462 Rocking bed with or without side rail
E0463 Pressure support ventilator with volume control mode used for invasive surfaces
E0464 Pressure support vent with volume control mode used for noninvasive surfaces
E0470 Respiratory Assist Device, bi-level pressure capability, without backup rate used non-invasive interface
E0471 Respiratory Assist Device, bi-level pressure capability, with backup rate for non-invasive interface
E0472 Respiratory Assist Device, bi-level pressure capability, with backup rate for invasive interface
E0480 Percussor electric/pneumatic home model
E0482 Cough stimulating device, alternating positive and negative airway pressure
E0483 High Frequency chest wall oscillation air pulse generator system
E0484 Oscillatory positive expiratory device, non-electric
E0570 Nebulizer with compressor
E0575 Nebulizer, ultrasonic, large volume
E0580 Nebulizer, durable, glass or autoclavable plastic, bottle type for use with regulator or flowmeter
E0585 Nebulizer with compressor & heater
E0601 Continuous airway pressure device
E0607 Home blood glucose monitor
E0627 Seat lift mechanism incorporated lift-chair
E0628 Separate Seat lift mechanism for patient owned furniture electric
E0629 Separate seat lift mechanism for patient owned furniture non-electric
E0636 Multi positional patient support system, with integrated lift, patient accessible controls
E0650 Pneumatic compressor non-segmental home mode
E0651 Pneumatic compressor segmental home model without calibrated gradient pressure
E0652 Pneumatic compressor segmental home model with calibrated gradient pressure
E0655 Non-segmental pneumatic appliance for use with pneumatic compressor on half arm
E0656 Non-segmental pneumatic appliance for use with pneumatic compressor on trunk
E0657 Non-segmental pneumatic appliance for use with pneumatic compressor on chest
E0660 Non-segmental pneumatic appliance for use with pneumatic compressor on full leg
E0665 Non-segmental pneumatic appliance for use with pneumatic compressor on full arm
E0666 Non-segmental pneumatic appliance for use with pneumatic compressor on half leg
E0667 Segmental pneumatic appliance for use with pneumatic compressor on full leg
E0668 Segmental pneumatic appliance for use with pneumatic compressor on full arm
E0669 Segmental pneumatic appliance for use with pneumatic compressor on half leg
E0671 Segmental gradient pressure pneumatic appliance full leg
E0672 Segmental gradient pressure pneumatic appliance full arm
E0673 Segmental gradient pressure pneumatic appliance half leg
E0675 Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency
E0692 Ultraviolet light therapy system panel treatment 4 foot panel
E0693 Ultraviolet light therapy system panel treatment 6 foot panel
E0694 Ultraviolet multidirectional light therapy system in 6 foot cabinet
E0720 Transcutaneous electrical nerve stimulation, two lead, local stimulation
E0730 Transcutaneous electrical nerve stimulation, four or more leads, for multiple nerve stimulation
E0731 Form fitting conductive garment for delivery of TENS or NMES
E0740 Incontinence treatment system, Pelvic floor stimulator, monitor, sensor and/or trainer
E0744 Neuromuscular stimulator for scoliosis
E0745 Neuromuscular stimulator electric shock unit
E0747 Osteogenesis stimulator, electrical, non-invasive, other than spine application
E0748 Osteogenesis stimulator, electrical, non-invasive, spinal application
E0749 Osteogenesis stimulator, electrical, surgically implanted
E0760 Osteogenesis stimulator, low intensity ultrasound, non-invasive
E0762 Transcutaneous electrical joint stimulation system including all accessories
E0764 Functional neuromuscular stimulator, transcutaneous stimulations of muscles of ambulation with computer controls
E0765 FDA approved nerve stimulator for treatment of nausea & vomiting
E0782 Infusion pumps, implantable, non-programmable
E0783 Infusion pump, implantable, programmable
E0784 External ambulatory infusion pump
E0786 Implantable programmable infusion pump, replacement
E0840 Tract frame attach to headboard, cervical traction
E0849 Traction equipment cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible
E0850 Traction stand, free standing, cervical traction
E0855 Cervical traction equipment not requiring addition stand or frame
E0856 Cervical traction device, cervical collar with inflatable air bladder
E0958 Manual wheelchair accessory, one-arm drive attachment
E0959 Manual wheelchair accessory, adapter for amputee
E0960 Manual wheelchair accessory, shoulder harness/strap
E0961 Manual wheelchair accessory wheel lock brake extension handle
E0966 Manual wheelchair accessory, headrest extension
E0967 Manual wheelchair accessory, hand rim with projections
E0968 Commode sear, wheelchair
E0969 Narrowing device wheelchair
E0971 Manual wheelchair accessory anti-tipping device
E0973 Manual wheelchair accessory, adjustable height, detachable armrest
E0974 Manual wheelchair accessory anti-rollback device
E0978 Manual wheelchair accessory positioning belt/safety belt/pelvic strap
E0980 Manual wheelchair accessory safety vest
E0981 Manual wheelchair accessory seat upholstery, replacement only
E0982 Manual wheelchair accessory, back upholstery, replacement only
E0983 Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, joystick control
E0984 Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, tiller control
E0985 Wheelchair accessory, seat lift mechanism
E0986 Manual wheelchair accessory, push activated power assist
E0990 Manual wheelchair accessory, elevating leg rest
E0992 Manual wheelchair accessory, solid seat insert
E0994 Arm rest
E1014 Reclining back, addition to pediatric size wheelchair
E1015 Shock absorber for manual wheelchair
E1020 Residual limb support system for wheelchair
E1028 Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory
E1029 Wheelchair accessory, ventilator tray
E1030 Wheelchair accessory, ventilator tray, gimbaled
E1031 Rollabout chair, any and all types with castors 5" or greater
E1035 Multi-positional patient transfer system with integrated seat operated by care giver
E1036 Patient transfer system
E1037 Transport chair, pediatric size
E1038 Transport chair, adult size up to 300lb
E1039 Transport chair, adult size heavy duty >300lb
E1161 Manual adult size wheelchair includes tilt in space
E1227 Special height arm for wheelchair
E1228 Special back height for wheelchair
E1232 Wheelchair, pediatric size, tilt-in-space, folding, adjustable with seating system
E1233 Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system
E1234 Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system
E1235 Wheelchair, pediatric size, rigid, adjustable, with seating system
E1236 Wheelchair, pediatric size, folding, adjustable, with seating system
E1237 Wheelchair, pediatric size, rigid, adjustable, without searing system
E1238 Wheelchair, pediatric size, folding, adjustable, without searing system
E1296 Special sized wheelchair seat height
E1297 Special sized wheelchair seat depth by upholstery
E1298 Special sized wheelchair seat depth and/or width by construction
E1310 Whirlpool non-portable
E2502 Speech generating devices prerecord messages between 8 and 20 minutes
E2506 Speech generating devices prerecord messages over 40 minutes
E2508 Speech generating devices message through spelling, manual type
E2510 Speech generating devices synthesized with multiple message methods
E2227 Rigid pediatric wheelchair adjustable
K0001 Standard wheelchair
K0002 Standard hemi (low seat) wheelchair
K0003 Light weight wheelchair
K0004 High strength ltwt wheelchair
K0005 Ultra lightweight wheelchair
K0006 Heavy duty wheelchair
K0007 Extra heavy duty wheelchair
K0009 Other manual wheelchair/base
K0606 AED garment with electronic analysis
K0730 Controlled dose inhalation drug delivery system

 

Resources

 

Last Updated Tue, 14 Sep 2021 19:09:32 +0000

The below are topic specific articles which have been published to "Latest Updates" and sent out in Noridian emails within the past two years. Exclusions to this include time sensitive related announcements such as: Noridian and CMS educational events, Ask-the-Contractor Teleconferences and claims processing downtime.

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Standard Elements for DMEPOS Order, and Master List of DMEPOS Items Potentially Subject to a Face-to-Face Encounter and Written Orders Prior to Delivery and, or Prior Authorization Requirements SE20007   08/14/2020