Much of the attention generated by the Medicare and Children’s Health Insurance Program Reauthorization Act (MACRA) focused on the repeal of the Sustainable Growth Rate and creation of the future Merit-based Incentive Payment System. However, another provision of MACRA reduces the face-to-face visit requirements for prescribing some durable medical equipment (DME).
As a condition for payment, section 6407 of the Affordable Care Act (ACA) requires that a physician, physician assistant, nurse practitioner, or clinical nurse specialist conduct a face-to-face examination with a Medicare beneficiary within the last six months before writing an order for certain items of DME. Section 6407 also required that a physician co-sign this examination if it was performed by a non-physician.
MACRA has eliminated this requirement.
All other aspects of the face-to-face requirement for DME prescriptions remain in place. Medicare requires a face-to-face examination each time a new prescription for one of the specified items is ordered, and Medicare requires a new prescription:
• For all claims for purchases or initial rentals.
• When there is a change in the prescription for the accessory, supply, drug, etc.
• If a local coverage determination requires periodic prescription renewal (i.e., policy requires a new prescription on a scheduled or periodic basis).
• When an item is replaced.
• When there is a change in the supplier.
The face-to-face examination must document that the beneficiary was evaluated or treated for a condition that supports the need for the prescribed DME. Remember that all Medicare coverage and documentation requirements for DME also apply, which means that there must be sufficient medical information included in the medical record to demonstrate that the applicable coverage criteria are met.
The treating physician or other qualified health care professional that conducts the face-to-face examination does not need to be the prescriber for the DME. However, the prescriber must verify that the qualifying in-person visit occurred within the six months prior to the date of their prescription and have documentation of the qualifying face-to-face examination. The prescriber must also provide a copy of the qualifying face-to-face examination and the prescription for the item or items to the DME supplier before the supplier can deliver them.
You can find additional information on these requirements on the Centers for Medicare & Medicaid Services web site.
– Kent Moore, Senior Strategist for Physician Payment for the American Academy of Family Physicians
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