CMS Adopts Face-to-Face Encounter Requirement for Medicare DME Orders

As part of CMS’s Medicare physician fee schedule rule, CMS is implementing an ACA provision requiring a face-to-face encounter as a condition of Medicare payment for certain DME items. CMS has made a number of modifications to the final policy in response to comments on the proposed rule. Under the final rule, CMS is expanding the written order requirements to provide that, as a condition of payment for specified items of DME, a physician must have documented and communicated to the DME supplier that the physician or a physician assistant, a nurse practitioner, or a clinical nurse specialist has had a face-to-face encounter with the beneficiary within the six month period before the written order. This provision is somewhat more liberal than the proposed rule, under which the face-to-face encounter would have been required no more than 90 days before or within 30 days after the order was written. However, CMS agreed with commenters that allowing the encounter to occur after the order was written could result in medically unnecessary items being delivered to beneficiaries. CMS also confirms that this 6-month deadline does not supersede the existing 45-day face-to-face encounter requirement for certain items, such as power mobility devices (PMDs), outlined in §410.38(c), which was issued under separate authority. The face-to-face encounter must be documented in accordance with specific CMS requirements, and include at a minimum: (1) the beneficiary name; (2) the item of DME ordered; (3) prescribing practitioner National Provider Identifier; (4) the signature of the prescribing practitioner; and (5) the date of the order (CMS removed the proposed requirement for orders to include “necessary and proper usage instructions” and the diagnosis). The supplier must retain the written order and supporting documentation for seven years after the date of service, and make it available to CMS on request. CMS will allow face-to-face encounters to be accomplished via a telehealth encounter if all other Medicare telehealth regulatory requirements are met. The initial items that will be subject to this provision include: items that currently require a written order prior to delivery under the Medicare Program Integrity Manual; items that cost more than $1,000; and items identified as particularly susceptible to fraud, waste, and abuse (CMS added a criterion to remove any items where regulations explicitly state that a face-to-face encounter is not necessary). CMS lists in Table 89 of the final rule the HCPCS codes for DME items that initially will subject to this provision; CMS will update the list through rulemaking as necessary. CMS also states its intention to apply the face-to-face encounter requirements to certain prosthetic devices, orthotics, and prosthetics in a future rulemaking. CMS has established a G-code (G0454) to provide a modest payment to the physician who documents a face-to-face encounter for the specified DME items. To allow sufficient time for implementation, CMS is extending the effective date of this provision to new orders for covered items written on or after July 1, 2013.  The official version of the rule will be published on November 16, 2012.

* 6/28/2013 UpdateCMS delays enforcement.

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