LEEDer Group Inc.
8508 North West 66th St.
Miami, Florida 33166 USA

Phone: 305.436.5030
Fax: 305.436.0086
E-mail Address: info {at] LEEDerGroup [dot] com

2013-07 Detailed Written Orders and Face-to-Face Encounters MM8304





MLN Matters®
Number: MM8304 Revised Related Change Request (CR) #: CR 8304
Related CR Release Date: May 31, 2013 Effective Date: July 1, 2013
Related CR Transmittal #: R468PI Implementation Date: July 1, 2013

Detailed Written Orders and Face-to-Face Encounters MM8304

Note: This article was revised on June 28, 2013, toprovide clarifying language on page 2 and to
provide a Web address for a relevant portion of the “Program Integrity Manual? on page 2. All other
information remains the same.

  • Provider Types Affected
    This MLN Matters® Article is intended for physicians, Physician Assistants (PAs), Nurse Practitioners (NPs), Clinical Nurse Specialists (CNSs) and suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for certain Durable Medical Equipment (DME) items and services provided to Medicare beneficiaries.
  • What You Need to Know
    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). (That section is available at http://www.gpo.gov/fdsys/pkg/CFR-2011-title42-vol2/pdf/CFR-2011-title42-vol2-sec410-38.pdfon the Internet.) 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 suppliersand 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 information on at http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/Medical-Review/index.htmlon 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.
  • Background
    As a condition for payment, Section 6407 of the Affordable Care Act requires a 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 this article). This section 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 telehealth (as described in Chapter15 of the “Medicare Benefit Policy Manual” and Chapter 12 of the “Medicare Claims Processing Manual”). Those manuals are available at http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html on the CMS website. Note that 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, orCNS, 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 (available at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Internt-Only-Manuals-IOMs-Items/CMS019033.html)and include, at a minimum;
    1. the beneficiary’s name,
    2. the item ofDME ordered,
    3. the prescribing practitioner’s National Provider Identifier (NPI),
    4. the signature of the ordering practitioner and
    5. 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/co-signing the faceto-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. CR8304 implements these changes inChapter 5 of the “Program Integrity Manual” to support 42 Code of Federal Regulations (CFR) 410.38(g) and the revised portion of that manual is attached to CR8304.
  • Additional Information
    The official instruction, CR8304, issued to your DME MAC regarding this change, may be viewed at http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R468PI.pdf on the CMS website. If you have any questions, please contact your DME MAC at their toll-free number, which may be found at http://www.cms.gov/Research-Statistics-Data-and-Systems/MonitoringPrograms/provider-compliance-interactive-map/index.htmlon the CMS website.