The Face-to-Face Exam Rule

At press time, the Centers for Medicare & Medicaid Services (CMS) announced a three month “enforcement delay” of the July 1, 2013 start date for implementing the new regulation requiring 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, 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. This new rule will essentially greatly expand the DME items subject to the “written order prior to delivery” requirement.

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 DME. In November 2012, 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. According to the regulation, the new procedures apply to new DME orders that occur on or after July 1, 2013. However, the “enforcement delay” presumably means that the rule will apply to new orders on or after October 1, 2013.

To date, the Medicare Program has provided minimal information about this new requirement. Aside from the November 16, 2012 final rule, the only additional Medicare document was posted by CMS in the first week of June 2013. This revision to CMS’ Program Integrity Manual provided no information beyond what CMS had published in its November 2012 final regulation. The CMS final rule’s preamble language states that there must be “sufficient documentation” in the beneficiary’s medical record to document that the beneficiary meets the Medicare medical policy requirements for the DME ordered. CMS states that the 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 six 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. That’s it for CMS information. At press time, we had seen no Medicare physician education documents.
 
What to do? DME providers will have to educate referral sources. You will need to refer physicians to the particular Medicare medical policy to understand what conditions qualify for the DME item and educate them on the fact that Medicare will want to see detailed notes in the patient’s medical record that correlate the beneficiary’s condition to the Medicare LCD criteria. Physicians are also required to provide that medical record documentation to the DME supplier, 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.”

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 be 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 published in Table 89 of the CMS final rule (see endnote reference).

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 face-to-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.

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.

See 42 C.F.R. 410.38(g) and 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)” Click here to view. For this and more information on the new face-to-face rule, go to Invacare’s web site and click on “Policy & Funding.”