In the 2013 Medicare Physician Fee Schedule proposed rule, the Centers for Medicare and Medicaid Services proposes to significantly expand the list of durable medical equipment items that require a detailed written order prior to delivery and will also require a face-to-face encounter.

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The 2013 Medicare Physician Fee Schedule (MPFS) proposed rule, released by the Centers for Medicare and Medicaid Services (CMS) on July 6, 2012, updates payment policies and payment rates for services furnished on or after January 1, 2013.  While this On The Subject discusses the proposed durable medical equipment (DME) written order and face-to-face encounter requirements, the proposed rule also includes the following changes:

  • Increase in payments for primary care specialties and decrease in payments to certain other specialties
  • Expansion of the Multiple Procedure Payment Reduction Policy
  • Modification of quality reporting programs associated with the MPFS, including the Physician Quality Reporting System, Electronic Prescribing Incentive Program, Medicare Electronic Health Records Incentive Pilot Program and Physician Compare Website
  • Continued implementation of the physician value-based payment modifier
  • Additional technical clarifications and updates  

Written Order Prior to Delivery and Face-to-Face Encounter Requirements

DME suppliers must obtain detailed written orders from a beneficiary’s treating physician prior to billing for covered DME.  The Social Security Act authorizes CMS to specify covered DME that requires a supplier to obtain a detailed written order prior to delivering the item.  The Medicare Program Integrity Manual contains the current list of DME that requires a detailed written order prior to delivery.  The list is relatively small and includes pressure-reducing pads, mattress overlays, mattresses and beds; seat lift mechanisms; transcutaneous electrical nerve stimulation (TENS) units; and power-operated vehicles and power wheelchairs, which were seen as posing vulnerabilities to the Medicare program that could be mitigated through requiring a written order prior to delivery.

Under the MPFS proposed rule, CMS proposes to expand the list of items that require a detailed written order prior to delivery.  The list of Specified Covered Items includes common DME, such as glucose monitors, respiratory assist devices, infusion pumps, and oxygen and oxygen equipment.  For each item on the list of Specified Covered Items, CMS also proposes to require DME suppliers to obtain documentation from the treating physician that the physician or a physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS) had a face-to-face encounter with the beneficiary no more than 90 days before or 30 days after the order was written.  The face-to-face encounter requirement is one of the anti-fraud provisions in the Affordable Care Act and is consistent with similar face-to-face requirements for the Medicare home health and Medicaid DME benefit.

Specified Covered Items

The proposed list of Specified Covered Items includes DME items that meet at least one of the following criteria:

  • Items that currently require a detailed written order prior to delivery per instructions in the Medicare Program Integrity Manual
  • Items that cost more than $1,000
  • Items that CMS, based on its experience and recommendations from the DME Medicare Administrative Contractors, believes are particularly susceptible to fraud, waste and abuse
  • Items CMS believes are vulnerable to fraud, waste and abuse based on reports of the U.S. Department of Health and Human Services Office of Inspector General, U.S. Government Accountability Office or other oversight entities

CMS proposes to annually update the list to add any item of DME (i) described by a health care common procedure coding system code for TENS units, rollabout chairs, wheelchair accessories, oxygen and respiratory equipment, hospital beds and accessories, and traction-cervical but not power mobility devices that are subject to already existing face-to-face requirements; (ii) that appears on the Durable Medical Equipment, Prosthetics, Orthotics and Supplies Fee Schedule with a price ceiling at or greater than $1,000; and (iii) that CMS adds to the list of Specified Covered Items through the notice and comment rulemaking process in order to reduce the risk of fraud, waste and abuse.  Updates to the list will appear annually in the Federal Register, and the full updated list will be available on CMS’s website.

Written Order Requirements

CMS proposes to revise 42 C.F.R. 410.38(g) to explicitly require that, as a condition of payment for Specified Covered Items, a written order must include beneficiary name, item of DME ordered, prescribing practitioner national provider identifier, signature of the prescribing practitioner, date of the order, beneficiary diagnosis and necessary proper usage instructions, as applicable.  Examples of necessary proper usage instruction could include duration of use, method of utilization and correct positioning.  While standards of practice may require that orders contain additional information, an order without these minimum elements would be considered incomplete and would not support a claim for payment.

Face-to-Face Encounter and Documentation Requirements

During the face-to-face encounter, the physician, PA, NP or CNS must have evaluated the beneficiary, conducted a needs assessment for the beneficiary, or treated the beneficiary for the medical condition that supports the need for each covered item of DME.  A single face-to-face encounter can support the need for multiple covered items of DME as long as it is clearly documented in the beneficiary’s medical record that the beneficiary was evaluated or treated for a condition that supports the need for each covered item of DME during the specified period of time.  A face-to-face encounter may be accomplished via a telehealth encounter if all Medicare telehealth requirements are met.

When the face-to-face encounter is performed by a physician, the following sections of the beneficiary’s medical record are considered sufficient and valid documentation of the encounter when submitted to the DME supplier and made available to CMS: history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans or other appropriate information.  When the face-to-face encounter is performed by a PA, NP or CNS, CMS is considering the following documentation options:

  • Having the physician sign an attestation
  • Having the physician sign or cosign relevant sections of the medical record
  • Having the physician initial the beneficiary’s history and physical examination for the date of the face-to-face encounter 

CMS is proposing to introduce a G-code with an estimated allowable of $15, to compensate a physician who documents that a PA, NP or CNS has performed a face-to-face encounter.  Only physicians who do not bill an evaluation and management code for the beneficiary are eligible for the new G-code payment.  If multiple written orders for covered items originate from one beneficiary visit, the physician can receive the G-code payment only once.

DME Supplier Notification of Face-to-Face Encounter

Since the DME supplier submits the claims for the covered DME items, the supplier must have access to the face-to-face encounter documentation.  CMS is considering the following options:

  • Requiring the practitioner who wrote the order to provide the physician documentation of the face-to-face encounter directly to the DME supplier
  • Requiring the physician who completed the documentation of the face-to-face encounter to provide documentation directly to the DME supplier
  • Requiring that the documentation be provided to the DME supplier through the same process as the written order regardless of who completes it
  • Requiring a physician to provide a copy of the documentation to the beneficiary for the beneficiary to deliver to the DME supplier

CMS will accept comments on the proposed rule until September 4, 2012.