1 The Medicare Face-to-Face Rules for Physicians Prescribing Durable Medical Equipment 2 A provision of the Affordable Care Act mandates that there must be documentation in the medical record by the physician or other prescribing practitioner of an in-person evaluation of the patient prior to prescribing some types of durable medical equipment (DME). Contained in the 2009 Health Reform Law, aka the Affordable Care Act - Section 6407(b) Medicare issued the final rule governing the Face-to-Face requirement for physicians prescribing durable medical equipment (DME) as part of Medicare Physician Payment Final Rule - November 16, 2012, 77 Federal Register 68891 New 42 Code of Federal Regulations (CFR) 410.38(g) What is the Rule? Evolution of the Rule 3 Documenting the Exam Keys to Sufficient Documentation A Face-to-Face Exam can be performed by physician, nurse practitioner, physician assistant or clinical nurse specialist The exam must occur within 6 months prior to prescribing the DME item(s) Exam occurrence must be documented in the patient’s medical record - The exam must include and document: • Evaluation of beneficiary • Needs assessment • Treatment • Relevant Diagnoses • Medical record must support medical need for DME ordered The medical record must contain enough pertinent clinical and other information to substantiate that the beneficiary meets the Medicare program’s requirements for the specific DME item ordered Ordering physician must provide that component of the patient’s medical record to the DME supplier Medicare Medical Policies for DME are located at: Jurisdiction A: medicarenhic/dme/index.asp Jurisdiction B: ngsmedicare/wps/portal/ngsmedicare/home Jurisdiction C: cgsmedicare/medicare.html Jurisdiction D: https://noridianmedicare/dme/index.html%3f 4 Additional Physician Obligations A Valid Written Order for DME If non-physician practitioner (NP, CNS, PA) conducts the face-to-face exam, the physician must still document in the medical record that the encounter occurred The Physician must co-sign the relevant part of the medical record to document that the NP, PA or CNS performed the exam - The signed DME item order is not sufficient After exam occurs, physician must provide the medical record documentation to the DME supplier, as well as the written order and any supporting documentation - CMS may request this documentation up to 7 years Medicare requires that 5 elements be met for a DME order to be considered valid: 1. Date of the order, and 2. Beneficiary name, and 3. Item of DME ordered (i.e, standard wheelchair) 4. The prescribing physician’s NPI (national provider identifier); and 5. Signature of prescribing practitioner 5 Physician Billing Resources/More Information G0454 – Medicare billing code for physicians - Intended to compensate physicians who co-sign and document that a PA, NP or CNS practitioner performed a face-to-face encounter for DME equipment The G-code does not apply if the physician bills an evaluation and management (E&M) code when the physician does the face-to-face exam him/herself If physician co-signs and documents that a PA, NP or CNS practitioner orders multiple items of DME, the physician is only eligible to bill for the G-code payment once Regulation is at 42 C.F.R. 410.38(g) CMS Final Rule: 77 Federal Register 68891 (November 16, 2012), Medicare Program; Revisions to Payment Policies Under the Physician Fee Schedule, DME Face-to-Face Encounters, Elimination of the Requirement for Termination of Non-Random Complex Medical Review and Other Revisions to Part B for CY 2013 Affordable Care Act, Section 6407(b) Invacare Corporation invacare © 2013 Invacare Corporation. All rights reserved. All trademarks are identified by the symbols ™ and ®. All trademarks are owned by or licensed to Invacare Corporation unless otherwise noted. Specifications are subject to change without notification. Form No. 13-356 130508 Invacare Corporation One Invacare Way Elyria, Ohio 44035-4190 (800) 333-6900 This information is not intended to be, nor should it be considered, medical, billing or legal advice. The physician and other medical care providers are responsible for determining proper product selection and the appropriate billing codes when submitting claims to the Medicare program, and should consult an attorney or other advisor to discuss specific situations in further detail.
Posted on: Wed, 19 Jun 2013 19:55:36 +0000