CMS tosses docs a bone, makes HMEs fetch stick

Wednesday, July 24, 2013

CMS has passed a rule stating that most DME items require a face-to-face encounter with a physician, PA, NP or CNS for payment. The implementation of this rule has been delayed from July 1 to Oct. 1, but it’s worth reviewing and preparing for the rule now. 

The requirement to have the supporting information contained directly in the patient’s medical record to justify payment has always been there. What this change means is that a patient can no longer simply call their primary care physician to request a DME item (the rule applies to more than 100 items, including mattress pads, hospital beds, portable oxygen systems and lift chairs to name a few) without scheduling a face-to-face evaluation with a practitioner prior to a written order (prescription). 

With everything that is going on in our industry at the moment, I wonder how many DME providers have had time to review this new requirement? In June, HME News reported that AAHomecare asked CMS to delay the July 1st start date, citing a need for clarifications and expressing concerns over timing. I agree with AAHomecare’s concerns and thought it typical for CMS to announce the start date of this new condition for payment to correspond with Round 2 of competitive bidding. Did CMS assume most DME providers were too busy working on strategies to stay in business (with or without the competitive bidding contracts), to research, find and read about Section 6407 of the Affordable Care Act? Perhaps. 

Here’s my summary of how this new requirement impacts the DME provider:

The face-to-face evaluation for all identified DME items must occur within six months prior to the written order. The date of the face-to-face evaluation must be before the date of the written order. If you have a client in need of a hospital bed, for example, you should recommend that they schedule an appointment with their practitioner for a face-to-face evaluation. 

The face-to-face encounter should be for the condition that supports the DME items(s) ordered. i.e., if the patient was seen for a flu shot, the applicable coverage policy for a standard (K0001) wheelchair cannot be added to that encounter’s notes. A patient who needs a manual chair should schedule an appointment with their primary care physician specifically for a face-to-face evaluation for that equipment.

If the face-to-face evaluation is conducted by a PA, NP (ARNP) or CNS, that encounter and/or the applicable coverage policy addition must be co-signed by an MD or DO. This presents a dilemma and hardship for rural health clinics with PAs and NPs only. 

One could argue that CMS threw physicians a bone, as they get to bill for their “time” to co-sign, using code G0454 (no corresponding billing was provided for the PAs or NPs to find an MD or DO to sign off on their notes). DME providers should not provide any of the items listed in this new requirement without a face-to-face evaluation and written order co-signed by a physician and expect Medicare coverage for the provided equipment. As with power mobility device items, especially in the seven prior authorization states, DME providers are completely dependent on and practically left begging practitioners for accurate and complete documentation.

In the past, the majority of DME providers have relied on meeting the coverage criteria by simply adding the applicable coverage policy to the detailed written order, believing this will meet the supporting documentation requirement. This practice is not necessarily a bad thing; however, it is important to remember that the information included on the written order must be corroborated in the practitioner’s medical record. The detailed written order is not considered part of the medical record; therefore, as a standalone it does not meet the coverage criteria. 

If these records have always been required, why is there now an additional face-to-face requirement? Because CMS wants accountability—to see that the equipment was ordered based on a clinical exam and that it is part of the patient’s treatment plan, not an afterthought. 

Finally, it appears that the list of DME items in this new face-to-face requirement has been partially created from the list of top 20 highest improper payments service types in 2011, though there are some HCPCS that are questionable. A complete list of specified covered DME items can be found online at in the MLN Matters Number: MM8304, released May 31st. 

My advice: DME providers should go to the or another reliable source frequently and check for new announcements. Always review new policies and procedures closely, and alert your intake and billing staff accordingly. Failure to obtain the required DME paperwork from your physicians will result in the denial of the claim when reviewed in a pre-or post-payment audit. Get your dates, signatures and paperwork in order. CMS does not sympathize with puppies caught with their tails between their legs.

Jamie Loper, ATP, is co-founder of She has more than 30 years of experience as a DME billing and compliance consultant.