The Medicare Face-to-Face Rules. for Durable Medical Equipment

The Medicare Face-to-Face Rules for Durable Medical Equipment 1

The Medicare Face-to-Face Rules for Durable Medical Equipment On October 1, 2013, the Medicare program will require physicians who order durable medical equipment (DME) for Medicare beneficiaries to conduct a face-to-face exam with the beneficiary that specifically addresses the need for the DME item (i.e., wheelchair, hospital bed), document this information in the patient s medical record and provide a copy of that medical record to the DME supplier who fulfills the order. Background: The 2009 Health Reform law included a provision requiring physicians (or a physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS)) to have a face-to-face encounter as a condition for payment for most items of DME. In November 2012, the Centers for Medicare and Medicaid Services (CMS) issued its final rule implementing this new requirement. This face-to-face exam requirement requires physicians to document in the beneficiary s medical record details about the beneficiary s condition that correlate to the medical need required by Medicare for the DME that is ordered during that visit, or that may be ordered in the following six months. Physicians must supply this documentation to the DME supplier, who will be required to have this documentation on file before they can submit the DME claim to Medicare for payment. The new procedures apply to new DME orders that occur on or after October 1, 2013. 2

The Basics of the Rule The face-to-face exam by the physician, NP, PA or CNS with the beneficiary must occur within six months prior to the written order for the DME. The physician or practitioner must document in the medical record the occurrence of the face-to-face encounter. This documentation must include an evaluation of the beneficiary, a needs assessment for the beneficiary, or treatment of the beneficiary for the medical condition that supports the need for each item of DME that is being ordered, or that may soon be ordered (within 6 months). Diagnoses related to the condition for which DME is or may soon be ordered should be documented in the medical record during the exam. When the physician performs the face-to-face encounter, there must be sufficient documentation in the pertinent portions of the beneficiary s medical record to document that the beneficiary meets the Medicare medical policy requirements for the DME ordered. Physicians should refer to the particular Medicare medical policy to understand what conditions qualify for the DME item (see For More Information ). Physicians are required to provide that medical record documentation to the DME supplier, who must have it before submitting the Medicare claim; and it must be available to the Medicare program upon request. If a non-physician practitioner conducts the face-to-face exam, the physician must still document that encounter in his/her medical records for that beneficiary. The physician is required to sign/cosign the pertinent portion of the medical record to document when a face-to-face encounter was performed by a NP, PA or CNS, thereby documenting that the beneficiary was evaluated or treated for a condition relevant to an item of DME on that date of service. A signed order for the DME item (in contrast to a signed medical record) does not satisfy the requirement that the physician sign/cosign the pertinent portion of the medical record. After the physician documents the exam, he/she must communicate such to the DME supplier. The DME supplier must have access to the documentation of the face-to-face encounter and must maintain the written order and all the supporting documentation and make them available to CMS upon request for seven years from the date of service. Because the face-to-face encounter is a condition of payment, the supplier must have all documentation to support the claim upon the request of Medicare. 3

Key Things Physicians Need to Know A written order is required by Medicare for coverage of all DME items. Medicare requires five minimum elements of a written order, which the physician/practitioner must document for the order to be considered valid: 1. Beneficiary s name; 2. Item of DME ordered; 3. Prescribing practitioner NPI (national provider identifier); 4. Signature of the prescribing practitioner; and, 5. The date of the order. The new face-to-face rule applies to most, but not all, items of DME. It applies to manual wheelchairs and accessories, beds, pads, hospital-type beds, some oxygen equipment, nebulizers, ventilators, CPAPs, blood glucose monitors, seat lifts, pneumatic compressors, infusion pumps and traction equipment. See the list of HCPCS codes requiring face-to-face exam. Medicare beneficiaries discharged from a hospital do not need to receive a separate face-to-face encounter, as long as the physician or treating practitioner who performed the face-to-face encounter in the hospital issues the DME order within six months after the date of discharge. The face-to-face requirement does not supersede any more specific regulatory requirements for faceto-face encounters such as those for power mobility devices (PMD). PMDs are not included in this requirement because they are already subject to a separate face-to-face encounter requirement with a 45- day period between the date of the face-to-face exam and the date of the written order. 4

Physician Payment for Certain DME Documentation The Medicare program has established a G billing code (G0454), estimated at $10-15, to compensate physicians who document that a PA, NP or CNS practitioner performed the face-to-face encounter for the list of specified DME items. This G-code does not apply when a physician bills an evaluation and management code when the physician performs the face-to-face encounter himself/herself. The G-codes may only be used when the physician documents a face-to-face encounter that is performed by a PA, NP or CNS. Additionally, if multiple orders for DME originate from one office visit, the physician is only eligible for the G-code payment once. For More Information CMS Final Rule: 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; Final Rule, 77 Federal Register 68891, November 16, 2012 (CMS-1590-FC) http://www.gpo.gov/fdsys/pkg/fr-2012-11-16/pdf/2012-26900.pdf 5

For More Information Medicare coverage policies for DME: Jurisdiction A: http://www.medicarenhic.com/dme/index.asp (Connecticut, Delaware, Maine, Maryland, Massachusetts, New Hampshire, New Jersey, New York, Pennsylvania, Rhode Island, Vermont and Washington, DC) Jurisdiction B: http://www.ngsmedicare.com/wps/portal/ngsmedicare/home (Illinois, Indiana, Kentucky, Michigan, Minnesota, Ohio and Wisconsin) Jurisdiction C: http://www.cgsmedicare.com/medicare.html (Alabama, Arkansas, Colorado, Florida, Georgia, Louisiana, Mississippi, New Mexico, North Carolina, Oklahoma, Puerto Rico, South Carolina, Tennessee, Texas, U.S. Virgin Islands, Virginia and West Virginia) Jurisdiction D: https://www.noridianmedicare.com/dme/index.html%3f (Alaska, American Samoa, Arizona, California, Guam, Hawaii, Idaho, Iowa, Kansas, N. Mariana Islands, Missouri, Montana, Nebraska, Nevada, North Dakota, Oregon, South Dakota, Utah, Washington and Wyoming) 6

DME Items Subject to the Medicare DME Face-to-Face Rule Effective October 1, 2013 HCPCS Code E0185 E0188 E0189 E0194 E0197 E0198 E0199 E0250 E0251 E0255 E0256 E0260 E0261 E0265 E0266 E0290 E0291 E0292 E0293 E0294 E0295 E0297 E0300 E0301 E0302 E0303 E0304 Description BEDS, PADS Gel or gel-like pressure mattress pad Synthetic sheepskin pad Lamb s wool sheepskin pad Air fluidized bed Air pressure pad for mattress standard length and width Water pressure pad for mattress standard length and width Dry pressure pad for mattress standard length and width Hospital bed fixed height with any type of side rails, mattress Hospital bed fixed height with any type side rails without mattress Hospital bed variable height with any type side rails with mattress Hospital bed variable height with any type side rails without mattress Hospital bed semi-electric (head and foot adjustment) with any type side rails with mattress Hospital bed semi-electric (head and foot adjustment) with any type side rails without mattress Hospital bed total electric (head, foot and height adjustments) with any type side rails with mattress Hospital bed total electric (head, foot and height adjustments) with any type side rails without mattress Hospital bed fixed height without rail with mattress Hospital bed fixed height without rail without mattress Hospital bed variable height without rail without mattress Hospital bed variable height without rail with mattress Hospital bed semi-electric (head and foot adjustment) without rail with mattress Hospital bed semi-electric (head and foot adjustment) without rail without mattress Hospital bed total electric (head, foot and height adjustments) without rail without mattress Pediatric crib, hospital grade, fully enclosed Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, without mattress Hospital bed Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, without mattress Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, with mattress Hospital bed Heavy Duty extra wide, with weight capacity greater than 600 lbs with any type of rail, with mattress 7

DME Items Subject to the Medicare DME Face-to-Face Rule Effective October 1, 2013 HCPCS Code E0424 E0431 E0433 E0434 E0439 E0441 E0442 E0443 E0444 E0450 E0457 E0459 E0460 E0461 E0462 E0463 E0464 E0470 E0471 E0472 E0480 E0482 E0483 E0484 E0570 E0575 E0580 E0585 E0601 E0607 Description OXYGEN, VENTS, CPAPs NEBULIZERS, OTHER RESPIRATORY Stationary compressed gas Oxygen System rental; includes contents, regulator, nebulizer, cannula or mask and tubing Portable gaseous oxygen system rental includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing Portable liquid oxygen system Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, cannula or mask, and tubing Stationary liquid oxygen system rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask and tubing Oxygen contents, gaseous (1 month supply) Oxygen contents, liquid (1 month supply) Portable oxygen contents, gas (1 month supply) Portable oxygen contents, liquid (1 month supply) Volume control ventilator without pressure support used with invasive interface Chest shell Chest wrap Negative pressure ventilator portable or stationary Volume control ventilator without pressure support node for a noninvasive interface Rocking bed with or without side rail Pressure support ventilator with volume control mode used for invasive surfaces Pressure support vent with volume control mode used for noninvasive surfaces Respiratory assist device, bi-level pressure capability, without backup rate used non-invasive interface Respiratory assist device, bi-level pressure capability, with backup rate for a non-invasive interface Respiratory assist device, bi-level pressure capability, with backup rate for invasive interface Percussor electric/pneumatic home model Cough stimulating device, alternating positive and negative airway pressure High Frequency chest wall oscillation air pulse generator system Oscillatory positive expiratory device, non-electric Nebulizer with compressor Nebulizer, ultrasonic, large volume Nebulizer, durable, glass or autoclavable plastic, bottle type for use with regulator or flowmeter Nebulizer with compressor & heater Continuous airway pressure device GLUCOSE MONITORS Home blood glucose monitor 8

DME Items Subject to the Medicare DME Face-to-Face Rule Effective October 1, 2013 HCPCS Code E0627 E0628 E0629 E0636 E0650 E0651 E0652 E0655 E0656 E0657 E0660 E0665 E0666 E0667 E0668 E0669 E0671 E0672 E0673 E0675 E0692 E0693 E0694 E0720 E0730 E0731 E0740 E0744 E0745 E0747 E0748 E0749 E0760 E0762 E0764 E0765 Description SEAT LIFTS, PNEUMATIC COMPRESSORS Seat lift mechanism incorporated lift-chair Separate seat lift mechanism for patient owned furniture electric Separate seat lift mechanism for patient owned furniture non-electric Multi positional patient support system, with integrated lift, patient accessible controls Pneumatic compressor non-segmental home model Pneumatic compressor segmental home model without calibrated gradient pressure Pneumatic compressor segmental home model with calibrated gradient pressure Non-segmental pneumatic appliance for use with pneumatic compressor on half arm Non-segmental pneumatic appliance for use with pneumatic compressor on trunk Non-segmental pneumatic appliance for use with pneumatic compressor chest Non-segmental pneumatic appliance for use with pneumatic compressor on full leg Non-segmental pneumatic appliance for use with pneumatic compressor on full arm Non-segmental pneumatic appliance for use with pneumatic compressor on half leg Segmental pneumatic appliance for use with pneumatic compressor on full leg Segmental pneumatic appliance for use with pneumatic compressor on full arm Segmental pneumatic appliance for use with pneumatic compressor on half leg Segmental gradient pressure pneumatic appliance full leg Segmental gradient pressure pneumatic appliance full arm Segmental gradient pressure pneumatic appliance half leg Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency Ultraviolet light therapy system panel treatment 4 foot panel Ultraviolet light therapy system panel treatment 6 foot panel Ultraviolet multidirectional light therapy system in 6 foot cabinet Transcutaneous electrical nerve stimulation, two lead, local stimulation Transcutaneous electrical nerve stimulation, four or more leads, for multiple nerve stimulation Form fitting conductive garment for delivery of TENS or NMES Incontinence treatment system, Pelvic floor stimulator, monitor, sensor and/or trainer Neuromuscular stimulator for scoliosis Neuromuscular stimulator electric shock unit Osteogenesis stimulator, electrical, non-invasive, other than spine application Osteogenesis stimulator, electrical, non-invasive, spinal application Osteogenesis stimulator, electrical, surgically implanted Osteogenesis stimulator, low intensity ultrasound, non-invasive Transcutaneous electrical joint stimulation system including all accessories Functional neuromuscular stimulator, transcutaneous stimulations of muscles of ambulation with computer controls FDA approved nerve stimulator for treatment of nausea & vomiting 9

DME Items Subject to the Medicare DME Face-to-Face Rule Effective October 1, 2013 HCPCS Code E0782 E0783 E0784 E0786 E0840 E0849 E0850 E0855 E0856 E0958 E0959 E0960 E0961 E0966 E0967 E0968 E0969 E0971 E0973 E0974 E0978 E0980 E0981 E0982 E0983 E0984 E0985 E0986 E0990 E0992 E0994 E0995 Description INFUSION PUMPS, TRACTION EQUIPMENT Infusion pumps, implantable, non-programmable Infusion pump, implantable, programmable External ambulatory infusion pump Implantable programmable infusion pump, replacement Tract frame attach to headboard, cervical traction Traction equipment cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible Traction stand, free standing, cervical traction Cervical traction equipment not requiring additional stand or frame Cervical traction device, cervical collar with inflatable air bladder MANUAL WHEELCHAIRS, ACCESSORIES Manual wheelchair accessory, one-arm drive attachment Manual wheelchair accessory-adapter for amputee Manual wheelchair accessory, shoulder harness/strap Manual wheelchair accessory wheel lock brake extension handle Manual wheelchair accessory, headrest extension Manual wheelchair accessory, hand rim with projections Commode seat, wheelchair Narrowing device wheelchair Manual wheelchair accessory anti-tipping device Manual wheelchair accessory, adjustable height, detachable armrest Manual wheelchair accessory anti-rollback device Manual wheelchair accessory positioning belt/safety belt/ pelvic strap Manual wheelchair accessory safety vest Manual wheelchair accessory, seat upholstery, replacement only Manual wheelchair accessory, back upholstery, replacement only Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, joystick control Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, tiller control Wheelchair accessory, seat lift mechanism Manual wheelchair accessory, push activated power assist Manual wheelchair accessory, elevating leg rest Manual wheelchair accessory, elevating leg rest solid seat insert Arm rest Wheelchair accessory calf rest 10

DME Items Subject to the Medicare DME Face-to-Face Rule Effective October 1, 2013 E1002 E1003 E1004 E1005 E1006 E1007 E1008 E1010 E1014 E1015 E1020 E1028 E1029 E1030 E1031 E1035 E1036 E1037 E1038 E1039 E1161 E1227 E1228 E1232 E1233 E1234 E1235 E1236 E1237 E1238 E1296 E1297 E1298 E2227 K0001 K0002 MANUAL WHEELCHAIRS, ACCESSORIES CONT. Wheelchair accessory power seating system, tilt only Wheelchair accessory power seating system, recline only without shear Wheelchair accessory power seating system, recline only with mechanical shear Wheelchair accessory power seating system, recline only with power shear Wheelchair accessory power seating system, tilt and recline without shear Wheelchair accessory power seating system, tilt and recline with mechanical shear Wheelchair accessory power seating system, tilt and recline with power shear Wheelchair accessory, addition to power seating system, power leg elevation system, including leg rest pair Reclining back, addition to pediatric size wheelchair Shock absorber for manual wheelchair Residual limb support system for wheelchair Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory Wheelchair accessory, ventilator tray Wheelchair accessory, ventilator tray, gimbaled Rollabout chair, any and all types with castors 5" or greater Multi-positional patient transfer system with integrated seat operated by caregiver Patient transfer system Transport chair, pediatric size Transport chair, adult size up to 300lb Transport chair, adult size heavy duty >300lb Manual Adult size wheelchair includes tilt-in-space Special height arm for wheelchair Special back height for wheelchair Wheelchair, pediatric size, tilt-in-space, folding, adjustable with seating system Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system Wheelchair, pediatric size, rigid, adjustable, with seating system Wheelchair, pediatric size, folding, adjustable, with seating system Wheelchair, pediatric size, rigid, adjustable, without seating system Wheelchair, pediatric size, folding, adjustable, without seating system Special sized wheelchair seat height Special sized wheelchair seat depth by upholstery Special sized wheelchair seat depth and/or width by construction Rigid pediatric wheelchair adjustable Standard wheelchair Standard hemi (low seat) wheelchair 11

DME Items Subject to the Medicare DME Face-to-Face Rule Effective October 1, 2013 K0003 K0004 K0005 K0006 K0007 K0009 K0606 E1310 E2502 E2506 E2508 E2510 Lightweight wheelchair High strength lightweight wheelchair Ultra lightweight wheelchair Heavy duty wheelchair Extra heavy duty wheelchair Other manual wheelchair/base AED garment with electronic analysis Whirlpool non-portable SPEECH GENERATING DEVICES Speech generating devices prerecord messages between 8 and 20 minutes Speech generating devices prerecord messages over 40 minutes Speech generating devices message through spelling, manual type Speech generating devices synthesized with multiple message 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. Invacare Corporation Invacare Corporation www.invacare.com One Invacare Way Elyria, Ohio 44035-4190 (800) 333-6900 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. 13-357 Rev. 07/13 130772 12