ACA: Section 6407 Face-to-Face Examinations
As a condition for payment, 42 CFR 410.38(g) requires that a treating physician/practitioner has had a face-to-face examination with a beneficiary within the six (6) months prior to the written order for certain items of DME.
For the treating physician/practitioner prescribing a specified DME item:
- Face-to-face examination with beneficiary must be conducted within the six (6) months prior to date of prescription
- Face-to-face examination must document that beneficiary was evaluated and/or treated for a condition that supports need for DME item(s) ordered
All other Medicare coverage and documentation requirements for DMEPOS also apply. There must be sufficient medical information included in the medical record to demonstrate that all other applicable coverage criteria are met. Refer to the applicable Local Coverage Determination (LCD) for information about the medical necessity criteria for the item(s) being ordered.
The treating physician/practitioner that conducted the face-to-face examination is not required to be the prescriber for the DME item; however, the prescriber must:
- Verify that the qualifying in-person visit occurred within the 6-months prior to date of prescription; and,
- Have documentation of qualifying face-to-face examination that was conducted
A new face-to-face examination is required each time a new prescription for one of the specified items is ordered.
Upon request by a contractor, all DMEPOS suppliers must provide documentation of the face-to-face examination.
- CMS Internet Only Manual (IOM), Publication 100-02, Medicare Benefit Policy Manual, Chapter 15
- CMS IOM, Publication 100-04, Medicare Claims Processing Manual, Chapter 12
Last Updated Jan 10, 2020