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IMPORTANT: THIS DOCUMENT CONTAINS OUTDATED INFORMATION.
Content provided on this page contains outdated information and instruction and should not be considered current. CGS is providing this archived information for research purposes only. This archived section contains previously issued instructions that have since been updated or are no longer applicable for Medicare billing purposes.

Originally Published February 20, 2014; May 29, 2014
Updated October 1, 2015

Face-to-Face Examination and Prescription Requirements Prior to the Delivery of Certain DME Items Specified in the Affordable Care Act - Revised

DME MAC Joint Publication

This revision incorporates changes in the prescription requirements based upon the Medicare Access and SCHIP Reauthorization Act of 2015.  The original provisions requiring that a physician co-sign a face-to-face examination that was performed by a PA, NP or CNS is removed.

As a condition for payment, Section 6407 of the Affordable Care Act (ACA) requires that a physician (MD, DO or DPM), physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS) has had a face-to-face examination with a beneficiary within the six (6) months prior to the written order for certain items of DME (Refer to Table A for a list of items).

A face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required by Medicare:

The first bullet above, claims for purchases or initial rentals, includes all claims for payment of purchases and initial rentals for items not originally covered (reimbursed) by Medicare Part B. Claims for items obtained outside of Medicare Part B, e.g. from another payer prior to Medicare participation (including Medicare Advantage plans), are considered to be new initial claims for Medicare payment purposes. This means that all Medicare payment requirements must be met, the same as any other item initially covered by Medicare.

These Affordable Care Act requirements are effective for claims for all of the specified items that require a new order (prescription) on or after July 1, 2013. Enforcement of these rules related to the face-to-face examination requirement and face-to-face documentation is delayed until further notice from CMS. This delay in enforcement does not apply to the prescription requirements for a Written Order Prior to Delivery or to the requirement to include the prescriber’s NPI on the prescription.

ACA 6407 also contained a provision requiring that an MD or DO co-sign the face-to-face examination performed by a PA, NP or CNS.  This requirement was eliminated by the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015.

Face-To-Face Examination Requirements

The physician must have a face-to-face examination with the beneficiary in the six (6) months prior to the date of the written order for the specified items of DME.
This face-to-face requirement includes examinations conducted via the Centers for Medicare & Medicaid Services (CMS)-approved use of telehealth examinations (as described in Chapter 15 of the Medicare Benefit Policy ManualExternal PDFand Chapter 12 of the Medicare Claims Processing ManualExternal PDF- CMS Internet-Only Manuals, Publ. 100-02 and 100-04, respectively).

The DMEPOS supplier must have documentation of both the face-to-face visit and completed written order prior to delivery (WOPD) in their file prior to the delivery of these items.
For the physician prescribing a specified DME item:

Prescription (order) Requirements

These specified items require a written order that must be obtained prior to delivery (WOPD). A WOPD is a standard Medicare detailed written order, which must be completed and in the DMEPOS supplier’s possession BEFORE the item is delivered. The prescription (order) for the DME must include all of the items below:

For any of the specified items provided on a periodic basis, including drugs, the written order must include:

For any of the specified items affected by this face-to-face requirement to be covered by Medicare, a written, signed and dated order must be received by the supplier prior to delivery of the item. If the supplier delivers the item prior to receipt of a written order, it will be denied as statutorily noncovered. If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.
Note that prescriptions for these specified DME items require the National Provider Identifier to be included on the prescription. Prescriptions for other DME items do not have this NPI requirement. Suppliers should pay particular attention to orders that include a mix of items, some of which are subject to these new order requirements. For example, oxygen concentrators (E1390) are often ordered in conjunction with portable oxygen (E0431). Orders for code E0431 require inclusion of the NPI while orders for E1390 do not.

Date and Timing Requirements

There are specific date and timing requirements:

A date stamp (or similar) is required which clearly indicates the supplier’s date of receipt of both the face-to-face record and the completed WOPD with the prescribing physician’s signature and signature date. It is recommended that both documents be separately date-stamped to avoid any confusion regarding the receipt date of these documents.

Claim Denial

Claims for the specified items subject to these face-to-face requirements and prescription requirements that do not meet the requirements specified above will be denied as statutorily noncovered - failed to meet statutory requirements.

Local Coverage Determinations (LCD) External Website

LCDs that contain items subject to these requirements are:

These LCDs will be updated to include the requirements at a future date.
Numerous items are not included in a specific LCD. Some have coverage criteria described by National Coverage Determinations. Others have coverage determined on a case-by-case or individual-claim basis. This article and the associated CMS publications will constitute notice of these requirements for all of the applicable codes.

Refer to the applicable LCD, NCD and/or the Supplier Manual for additional information about WOPD requirements.

TABLE A: DME List of Specified Covered Items
The DME list of Specified Covered Items is as follows. The original list was at 77 FR 44798. This original list contains some codes (codes marked with an “*”) that have been deleted or that were made not valid for Medicare while other codes (codes marked with an “**”) have had narrative changes. Updates to the list will be made as CMS releases revisions.

Refer to the Pricing, Data Analysis and Coding Contractor web site for information on coding at: http://www.dmepdac.comExternal Website

HCPCS Code

Description

E0185

Gel or gel-like pressure mattress pad

E0188

Synthetic sheepskin pad

E0189

Lamb's wool sheepskin pad

E0194

Air fluidized bed

E0197

Air pressure pad for mattress standard length and width

E0198

Water pressure pad for mattress standard length and width

E0199

Dry pressure pad for mattress standard length and width

E0250

Hospital bed fixed height with any type of side rails, mattress

E0251

Hospital bed fixed height with any type side rails without mattress

E0255

Hospital bed variable height with any type side rails with mattress

E0256

Hospital bed variable height with any type side rails without mattress

E0260

Hospital bed semi-electric (Head and foot adjustment) with any type side rails with mattress

E0261

Hospital bed semi-electric (head and foot adjustment) with any type side rails without mattress

E0265

Hospital bed total electric (head, foot and height adjustments) with any type side rails with mattress

E0266

Hospital bed total electric  (head, foot and height adjustments) with any type side rails without mattress

E0290

Hospital bed fixed height without rails with mattress

E0291

Hospital bed fixed height without rail without mattress

E0292

Hospital bed variable height without rail without mattress

E0293

Hospital bed variable height without rail with mattress

E0294

Hospital bed semi-electric (head and foot adjustment) without rail with mattress

E0295

Hospital bed semi-electric (head and foot adjustment) without rail without mattress

E0296

Hospital bed total electric (head, foot and height adjustments) without rail with mattress

E0297

Hospital bed total electric (head, foot and height adjustments) without rail without mattress

E0300

Pediatric crib, hospital grade, fully enclosed

E0301

Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, without mattress

E0302

Hospital bed Heavy Duty extra wide, with weight capacity  greater than 600 lbs with any type of rail, without mattress

E0303

Hospital bed Heavy Duty extra wide, with weight capacity 350-600 lbs with any type of rail, with mattress

E0304

Hospital bed Heavy Duty extra wide, with weight capacity  greater than 600 lbs with any type of rail, with mattress

E0424

Stationary compressed gas Oxygen System rental; includes contents, regulator, nebulizer, cannula or mask and tubing

E0431

Portable gaseous oxygen system rental includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing

E0433

Portable liquid oxygen system

E0434

Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, cannula or mask, and tubing

E0439

Stationary liquid oxygen system rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing

E0441

Oxygen contents, gaseous (1 months supply)

E0442

Oxygen contents, liquid (1 months supply)

E0443

Portable Oxygen contents, gas (1 months supply)

E0444

Portable oxygen contents, liquid (1 months supply)

E0450

Volume control ventilator without pressure support used with invasive interface

E0457

Chest shell

E0459

Chest wrap

E0460

Negative pressure ventilator portable or stationary

E0461

Volume control ventilator without pressure support node for a noninvasive interface

E0462

Rocking bed with or without side rail

E0463

Pressure support ventilator with volume control mode used for invasive surfaces

E0464

Pressure support vent with volume control mode used for noninvasive surfaces

E0470

Respiratory Assist Device, bi-level pressure capability, without backup rate used non-invasive interface

E0471

Respiratory Assist Device, bi-level pressure capability,  with backup rate for a non-invasive interface

E0472

Respiratory Assist Device, bi-level pressure capability, with backup rate for invasive interface

E0480

Percussor electric/pneumatic home model

E0482

Cough stimulating device, alternating positive and negative airway pressure

E0483

High Frequency chest wall oscillation air pulse generator system

E0484

Oscillatory positive expiratory device, non-electric

E0570

Nebulizer with compressor

E0575

Nebulizer, ultrasonic, large volume

E0580

Nebulizer, durable, glass or autoclavable plastic, bottle type for use with regulator or flowmeter

E0585

Nebulizer with compressor & heater

E0601

Continuous airway pressure device

E0607

Home blood glucose monitor

E0627

Seat lift mechanism incorporated lift-chair

E0628

Separate Seat lift mechanism for patient owned furniture electric

E0629

Separate seat lift mechanism for patient owned furniture non-electric

E0636

Multi positional patient support system, with integrated lift, patient accessible controls

E0650

Pneumatic compressor non-segmental home model

E0651

Pneumatic compressor segmental home model without calibrated gradient pressure

E0652

Pneumatic compressor segmental home model with calibrated gradient pressure

E0655

Non- segmental pneumatic appliance for use with pneumatic compressor  on half arm

E0656

Non- segmental pneumatic appliance for use with pneumatic compressor  on trunk

E0657

Non- segmental pneumatic appliance for use with pneumatic compressor  chest

E0660

Non- segmental pneumatic appliance for use with pneumatic compressor  on full leg

E0665

Non- segmental pneumatic appliance for use with pneumatic compressor  on full arm

E0666

Non- segmental pneumatic appliance for use with pneumatic compressor  on half leg

E0667

Segmental pneumatic appliance for use with pneumatic compressor  on full-leg

E0668

Segmental pneumatic appliance for use with pneumatic compressor  on full arm

E0669

Segmental pneumatic appliance for use with pneumatic compressor  on half leg

E0671

Segmental gradient pressure pneumatic appliance full leg

E0672

Segmental gradient pressure pneumatic appliance full arm

E0673

Segmental gradient pressure pneumatic appliance half leg

E0675

Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency

E0692

Ultraviolet light therapy system panel treatment 4 foot panel

E0693

Ultraviolet light therapy system panel treatment 6 foot panel

E0694

Ultraviolet multidirectional light therapy system in 6 foot cabinet

E0720

Transcutaneous electrical nerve stimulation,  two lead, local stimulation

E0730

Transcutaneous electrical nerve stimulation, four or more leads, for multiple nerve stimulation

E0731

Form fitting conductive garment for delivery of TENS or NMES

E0740

Incontinence treatment system, Pelvic floor stimulator, monitor, sensor, and/or trainer

E0744

Neuromuscular stimulator for scoliosis

E0745

Neuromuscular stimulator electric shock unit

E0747

Osteogenesis stimulator, electrical, non-invasive, other than spine application.

E0748

Osteogenesis stimulator, electrical, non-invasive, spinal application

E0749

Osteogenesis stimulator, electrical, surgically implanted

E0760

Osteogenesis stimulator, low intensity ultrasound, non-invasive

E0762

Transcutaneous electrical joint stimulation system including all accessories

E0764

Functional neuromuscular stimulator, transcutaneous stimulations of muscles of ambulation with computer controls

E0765

FDA approved nerve stimulator for treatment of nausea & vomiting

E0782

Infusion pumps, implantable, Non-programmable

E0783

Infusion pump, implantable, Programmable

E0784

External ambulatory infusion pump

E0786

Implantable programmable infusion pump, replacement

E0840

Tract frame attach to headboard, cervical traction

E0849

Traction equipment cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible

E0850

Traction stand, free standing, cervical traction

E0855

Cervical traction equipment not requiring additional stand or frame

E0856

Cervical traction device, cervical collar with inflatable air bladder

E0958**

Manual wheelchair accessory, one-arm drive attachment

E0959**

Manual wheelchair accessory-adapter for Amputee

E0960**

Manual wheelchair accessory, shoulder harness/strap

E0961**

Manual wheelchair accessory wheel lock brake extension handle

E0966**

Manual wheelchair accessory, headrest extension

E0967**

Manual wheelchair accessory, hand rim with projections

E0968*

Commode seat, wheelchair

E0969*

Narrowing device wheelchair

E0971**

Manual wheelchair accessory anti-tipping device

E0973**

Manual wheelchair accessory, adjustable height, detachable armrest

E0974**

Manual wheelchair accessory anti-rollback device

E0978*

Manual wheelchair accessory positioning belt/safety belt/ pelvic strap

E0980*

Manual wheelchair accessory safety vest

E0981**

Manual wheelchair accessory  Seat upholstery, replacement only

E0982**

Manual wheelchair accessory, back upholstery, replacement only

E0983**

Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, joystick control

E0984**

Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, Tiller control

E0985

Wheelchair accessory, seat lift mechanism

E0986**

Manual wheelchair accessory, push activated power assist

E0990**

Manual wheelchair accessory, elevating leg rest

E0992**

Manual wheelchair accessory, elevating leg rest solid seat insert

E0994*

Arm rest

E1014

Reclining back, addition to pediatric size wheelchair

E1015

Shock absorber for manual wheelchair

E1020

Residual limb support system for wheelchair

E1028**

Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory

E1029**

Wheelchair accessory, ventilator tray

E1030**

Wheelchair accessory, ventilator tray, gimbaled

E1031

Rollabout chair, any and all types with castors 5" or greater

E1035**

Multi-positional patient transfer system with integrated seat operated by care giver

E1036**

Patient transfer system

E1037

Transport chair, pediatric size

E1038**

Transport chair, adult size up to 300lb

E1039**

Transport chair, adult size heavy duty >300lb

E1161

Manual Adult size wheelchair includes tilt in space

E1227*

Special height arm for wheelchair

E1228*

Special back height for wheelchair

E1232

Wheelchair, pediatric size, tilt-in-space, folding, adjustable with seating system

E1233**

Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system

E1234

Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system

E1235

Wheelchair, pediatric size, rigid, adjustable, with seating system

E1236

Wheelchair, pediatric size, folding, adjustable, with seating system

E1237

Wheelchair, pediatric size, rigid, adjustable, without seating system

E1238

Wheelchair, pediatric size, folding, adjustable, without seating system

E1296*

Special sized wheelchair seat height

E1297*

Special sized wheelchair seat depth by upholstery

E1298*

Special sized wheelchair seat depth and/or width by construction

E1310**

Whirlpool non-portable

E2502**

Speech Generating Devices prerecord messages between 8 and 20 Minutes

E2506**

Speech Generating Devices prerecord messages over 40 minutes

E2508**

Speech Generating Devices message through spelling, manual type

E2510**

Speech Generating Devices synthesized with multiple message methods

E2227**

Rigid pediatric wheelchair adjustable

K0001

Standard wheelchair

K0002

Standard hemi (low seat) wheelchair

K0003

Lightweight wheelchair

K0004

High strength ltwt wheelchair

K0005

Ultra Lightweight wheelchair

K0006

Heavy duty wheelchair

K0007

Extra heavy duty wheelchair

K0009

Other manual wheelchair/base

K0606**

AED garment with electronic analysis

K0730

Controlled dose inhalation drug delivery system

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