April 26th, 2018
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns that some providers and suppliers may need additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act for certain items of DME, the Centers for Medicare & Medicaid Services (CMS) will start actively enforcing and will expect full compliance with the DME face-to-face requirements beginning on October 1, 2013.
Section 6407 of the Affordable Care Act established a face-to-face encounter requirement for certain items of DME. The law requires that a physician must document that a physician, nurse practitioner, physician assistant or clinical nurse specialist has had a face-to-face encounter with the patient. The encounter must occur within the 6 months before the order is written for the DME.
Although many durable medical equipment suppliers and physicians are aware of and are able to comply with this policy, CMS is concerned that some may need additional time to establish operational protocols necessary to comply with this new law. As such, CMS expects that during the next several months, suppliers and physicians who order certain DME items will continue to collaborate and establish internal processes to ensure compliance with the face-to-face requirement. CMS expects durable medical equipment suppliers to have fully established such internal processes and have appropriate documentation of required encounters by October 1, 2013.
CMS will continue to address industry questions concerning the new requirements and will update informatio on the CMS website. CMS and its contractors will also use other communication channels to ensure that the provider community is properly informed of this announcement.
As a condition for payment it is required for the physician to document that the physician, PA, NP or CNS has had a face-to-face encounter examination with a beneficiary in the six (6) months prior to the written order for certain items of DME (the complete list of items is found in Appendix A at the end of the referenced MLN).
NOTE: This does not apply to Power Mobility Devices (PMDs) as these items are covered under a separate requirement. This includes encounters conducted via the Centers for Medicare & Medicaid Services (CMS)-approved use of.
The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations.
The date of the written order must not be prior to the date of the face-to-face encounter. The face-to-face encounter conducted by the physician, PA, NP, or CNS must document that the beneficiary was evaluated and/or treated for a condition that supports the item(s) of DME ordered. In the case of a DME ordered by a PA, NP, or CNS, a physician (MD or DO) must document the occurrence of a face-to-face encounter by signing/co-signing and dating the pertinent portion of the medical record. CMS will accept a single confirming signature, including the date, as sufficient if there are several pertinent portions of the medical record.
The written order for the DME must follow the guidance in the CMS “Program Integrity Manual,” Chapter 5, Section 5.2.3 and include, at a minimum;
The beneficiary's name,
The item of DME ordered,
The prescribing practitioner's National Provider Identifier (NPI),
The signature of the ordering practitioner and
The date of the order.
Failure to meet any of the above requirements will result in denial of the claim. Physicians will be provided an additional payment, using code G0454, for signing/cosigning the face-to-face encounter of the PA/NP/CNS.
The physician should not bill the G code when he/she conducts the face-to-face encounter. Note that the G code may only be paid to the physician one time per beneficiary per encounter, regardless of the number of covered items documented in the face-to-face encounter.