8304 R468PI

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CMS Manual System

Department of Health &
Human Services (DHHS)

Pub 100-08 Medicare Program Integrity

Centers for Medicare &
Medicaid Services (CMS)

Transmittal 468

Date: May 31. 2013

Change Request 8304
SUBJECT: Detailed Written Orders and Face-to-Face Encounters
I. SUMMARY OF CHANGES: The purpose of this change request (CR) is to implement changes to Pub.
100-08, Medicare Program Integrity Manual to support 42 CFR 410.38(g) which is effective July 1, 2013.
EFFECTIVE DATE: July 1, 2013
IMPLEMENTATION DATE: July 1, 2013
Disclaimer for manual changes only: The revision date and transmittal number apply only to red
italicized material. Any other material was previously published and remains unchanged. However, if this
revision contains a table of contents, you will receive the new/revised information only, and not the entire
table of contents.
II. CHANGES IN MANUAL INSTRUCTIONS: (N/A if manual is not updated)
R=REVISED, N=NEW, D=DELETED-Only One Per Row.
R/N/D

CHAPTER / SECTION / SUBSECTION / TITLE

R

5/Table of Contents

N

5/5.2.3.2/ Detailed Written Orders for Face-to-Face Encounter

N

5/5.2.3.2.1/ Face-to-Face Encounter Conducted by the Physician

N

5/5.2.3.2.2 /Face-to-Face Encounter Conducted by a Physician Assistant, Nurse
Practitioner, or Clinical Nurse Specialist

N

5/5.2.3.2.3 /Detailed Written Orders for Covered Items

III. FUNDING:
For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs) and/or Carriers:
Not Applicable.
For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS does not construe this as a change to the MAC statement of Work. The contractor is
not obliged to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.
IV. ATTACHMENTS:
Business Requirements
Manual Instruction
*Unless otherwise specified, the effective date is the date of service.

Attachment - Business Requirements
Pub. 100-08

Transmittal: 468

Date: May 31, 2013

Change Request: 8304

SUBJECT: Detailed Written Orders and Face-to-Face Encounters
EFFECTIVE DATE: July 1, 2013
IMPLEMENTATION DATE: July 1, 2013
I.

GENERAL INFORMATION

A. Background: As a condition for payment, section 6407 of the Affordable Care Act requires a
physician to document that the physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse
specialist (CNS) has had a face-to-face encounter examination with a beneficiary in the six (6) months prior
to the written order for certain items of Durable Medical Equipment (DME). This section does not apply to
Power Mobility Devices (PMDs) as these items are covered under a separate requirement.
Physicians will be provided an additional payment, using G0454, for signing/co-signing the face-to-face
encounter of the PA/NP/CNS. The physician should not bill the G-code when he/she does the face-to-face
encounter. NOTE: The G-code may only be paid to the physician one time per beneficiary per encounter,
regardless of the number of covered items documented in the face-to-face encounter.
B. Policy: Section 6407 of the Affordable Care Act establishes a face-to-face encounter with a physician
or PA/NP/CNS and the Medicare beneficiary as a condition of payment for certain DME items. This
includes encounters conducted via CMS-approved telehealth (as described by CMS Pub 100-02, Medicare
Benefit Policy Manual, Chapter 15 and Pub. 100-04 Medicare Claims Processing Manual, Chapter 12).
II.

BUSINESS REQUIREMENTS TABLE

Number

Requirement

Responsibility
A/B
D F
MAC M I
E
A B H
H M
H A
C
X

C
A
R
R
I
E
R

R
SharedH
System
H Maintainers
I F M V C
I C M W
S S S F
S

Other

8304.1

When an applicable claim is selected for
review, contractors shall deny the claim if there
is no face-to-face encounter for covered items
as defined in 42 CFR 410.38(g).

CERT,
RA

8304.2

Contractors shall not apply this requirement to
PMDs.

X

CERT,
RA

8304.3

When an applicable claim is selected for
review, contractors shall verify that the
physician, PA/NP/CNS, has conducted a faceto-face encounter with the beneficiary.

X

CERT,
RA

8304.4

When an applicable claim where a PA/NP/CNS
conducted the face-to-face encounter is selected
for review, the contractor shall verify that a
physician has signed/co-signed the face-to-face

X

CERT,
RA

Number

Requirement

Responsibility
A/B
D F
MAC M I
E
A B H
H M
H A
C

C
A
R
R
I
E
R

R
SharedH
System
H Maintainers
I F M V C
I C M W
S S S F
S

Other

encounter to document the occurrence of the
face-to-face encounter.
8304.5

When an applicable claim is selected for
review, the contractor shall verify that the faceto-face encounter documentation includes
information supporting that the beneficiary was
evaluated and/or treated for a condition that
supports the item(s) of DME ordered.

X

CERT,
RA

8304.6

When an applicable claim is selected for
review, contractors shall deny the claim if
supporting information is not included and/or
the detailed written order was completed before
the face-to-face encounter.

X

CERT,
RA

8304.7

When an applicable claim is selected for
review, contractors shall ensure, for covered
items, that the detail written order is consistent
with instructions in section 5.2.3 of the
Program Integrity Manual (IOM 100-08).

X

CERT,
RA

8304.8

When an applicable claim is selected for
review, contractors shall deny the claim if the
beneficiary's name, the item of DME ordered,
the ordering practitioner's NPI, the signature of
the ordering practitioner and the date of the
order, are not included on the detailed written
order.

X

CERT,
RA

III.

PROVIDER EDUCATION TABLE

Number

Requirement

Responsibility
A/B
MAC
A

8304.9

IV.

MLN Article: A provider education article
related to this instruction will be available at
http://www.cms.gov/Outreach-andEducation/Medicare-Learning-NetworkMLN/MLNMattersArticles/ shortly after the
CR is released. You will receive notification of
the article release via the established "MLN
Matters" listserv. Contractors shall post this
article, or a direct link to this article, on their
Web sites and include information about it in a
listserv message within one week of the
availability of the provider education article. In
addition, the provider education article shall be
included in the contractor’s next regularly
scheduled bulletin. Contractors are free to
supplement MLN Matters articles with localized
information that would benefit their provider
community in billing and administering the
Medicare program correctly.

B

D F C R
M I A H
E
R H
R I
H
I
H M
A
E
H
C
R
X

Other

SUPPORTING INFORMATION

Section A: Recommendations and supporting information associated with listed requirements: N/A
X-Ref
Requirement
Number

Recommendations or other supporting information:

Section B: All other recommendations and supporting information: N/A
V. CONTACTS
Pre-Implementation Contact(s): Amanda Burd, 410-786-2074 or amanda.burd@cms.hhs.gov
Post-Implementation Contact(s): Contact your Contracting Officer's Representative (COR) or Contractor
Manager, as applicable.

VI. FUNDING
Section A: For Fiscal Intermediaries (FIs), Regional Home Health Intermediaries (RHHIs), and/or
Carriers:
Not Applicable.
Section B: For Medicare Administrative Contractors (MACs):
The Medicare Administrative Contractor is hereby advised that this constitutes technical direction as defined
in your contract. CMS do not construe this as a change to the MAC Statement of Work. The contractor is not
obligated to incur costs in excess of the amounts allotted in your contract unless and until specifically
authorized by the Contracting Officer. If the contractor considers anything provided, as described above, to
be outside the current scope of work, the contractor shall withhold performance on the part(s) in question
and immediately notify the Contracting Officer, in writing or by e-mail, and request formal directions
regarding continued performance requirements.

Medicare Program Integrity Manual
Chapter 5 – Items and Services Having Special DME Review
Considerations
Table of Contents
(Rev.468, Issued: 05-31-13)

Transmittals for Chapter 5
5.2.3.2- Detailed Written Orders for Face-to-Face Encounter
5.2.3.2.1 – Face-to-Face Encounter Conducted by the Physician
5.2.3.2.2 – Face-to-Face Encounter Conducted by a Physician Assistant, Nurse Practitioner, or
Clinical Nurse Specialist
5.2.3.2.3 – Detailed Written Orders for Covered Items

5.2.3.2 – Detailed Written Orders for Face-to-Face Encounter
(Rev.468; Issued: 05-31-13; Effective: 07-01-13; Implementation: 07-01-13)
This section only applies to covered items as defined in 42 CFR 410.38(g). CMS will notify contractors of
any annual updates to the list of covered items. CMS will notify the public of any updates in the list of
covered items via the Federal Register. Contractors shall not apply this section to PMDs.
For covered items as defined in 42 CFR 410.38(g) a physician must document that the physician, a
physician assistant (PA), a nurse practitioner (NP) or a clinical nurse specialist (CNS) has had a face-toface encounter with the beneficiary within six (6) months prior to completing the detailed written order. On
claims selected for review if there is no face-to-face encounter, contractors shall deny the claim.
5.2.3.2.1 – Face-to-Face Encounter Conducted by the Physician
(Rev.468; Issued: 05-31-13; Effective: 07-01-13; Implementation: 07-01-13)
When conducting a review of a covered DME item, outlined in 42 CFR 410.38(g) ordered by a physician
(MD or DO), the contractor shall ensure that the physician saw the beneficiary (including through the
appropriate use of telehealth (see Pub 100-02, the Medicare Benefit Policy Manual, Chapter 15 and Pub
100-04, the Medicare Claims Processing Manual, Chapter 12 ) and conducted a face-to-face assessment.
The contractor shall verify that the face-to-face documentation includes information supporting that the
beneficiary was evaluated or treated for a condition that supports the item(s) of DME ordered. If this
information is not included, the contractor shall deny the claim. If the physician completed the detailed
written order before the face-to-face encounter, the contractor shall deny the claim.
5.2.3.2.2 – Face-to-Face Encounter Conducted by a Nurse Practitioner, Physician Assistant or Clinical
Nurse Specialist
(Rev.468; Issued: 05-31-13; Effective: 07-01-13; Implementation: 07-01-13)
When conducting a review of a covered DME item, outlined in 42 CFR 410.38(g) ordered by a PA, NP, or
CNS, the contractor must ensure that the practitioner who conducted the face-to-face assessment saw the
beneficiary (including through the appropriate use of telehealth (see Pub 100-02, the Medicare Benefit
Policy Manual, Chapter 15 and Pub 100-04, the Medicare Claims Processing Manual, Chapter 12 ). If the
face-to-face encounter documentation does not include information supporting that the beneficiary was
evaluated or treated for a condition that supports the item(s) of DME ordered the contractor shall deny the
claim.
When conducting a review of a covered DME item, outlined in 42 CFR 410.38(g) ordered by a PA, NP, or
CNS, the contractor shall verify that a physician (MD or DO) documented the occurrence of a face-to-face
encounter by signing/co-signing and dating (consistent with the signature requirement in PIM Chapter 3,
Section 3.3.2.4) the pertinent portion of the medical record indicating the occurrence of a face-to-face. If
this information is not included, the contractor shall deny the claim.
NOTE: A single confirming signature and date is sufficient in a situation where there are several pertinent
portions of the medical record.
5.2.3.2.3 – Detailed Written Order for Covered Items
(Rev.468; Issued: 05-31-13; Effective: 07-01-13; Implementation: 07-01-13)
For a covered DME item, outlined in 42 CFR 410.38(g), the contractor shall ensure that the detailed written
order is consistent with PIM Chapter 5 § 5.2.3. Consistent with 42 CFR 410.38(g) the order must include,
at a minimum; the beneficiary’s name, the item of DME ordered, the prescribing practitioner’s NPI, the
signature of the ordering practitioner (physician, PA, NP, or CNS) and the date of the order. If this
information is not included on the detailed written order, the claim will be denied. Medicare requires that
the detailed written order is completed after the face-to-face encounter. If the date of the detailed written
order is prior to the date of the face-to-face encounter, the contractor shall deny the claim.



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