Requirements for Physicians Orders for DME/HCPCS

March 2nd, 2017 - Chris Woolstenhulme, CPC, CMRS
Categories:   DME|Supplies|Equipment   Practice Management  

Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed may be denied as non-covered if a proper order is not on file. Without proper physicians orders, reimbursement is not made and by contractual agreement the patient is not liable. 

If you are dispensing in your office be sure you are a contracted supplier with a DME number. If you are are the referring or the ordering physician/supplier be sure the following requirements are met:

Physician Orders:  The supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) is required to keep on file a physician prescription (order).  A supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary. 

Verbal and Preliminary Written Orders:  With some exceptions suppliers may dispense most items of DMEPOS based on a verbal order or preliminary written order from the treating physician.   

  • NOTE: If the supplier does not have an order from the treating physician before dispensing an item, the contractor shall consider the item as noncovered.

Covered orders must include:

  • description of the item
  • the beneficiary's name
  • the physician's name
  • start date of the order
  • the DME item ordered
  • the NPI of the prescribing physician/practitioner
  • signature of the prescribing physician/practitioner and the date of the order.

**If this information is not included on the written order, the claim will be denied**

Medicare requires that the written order is completed after the face-to-face encounter. If the date of the written order is prior to the date of the face-to-face encounter, the contractor shall deny the claim.

Suppliers must maintain the preliminary written order or written documentation of the verbal order and this documentation must be available to the DME MACs, Zone Program Integrity Contractors (ZPICs) or other CMS review contractor upon request.  If the supplier does not have an order from the treating physician before dispensing an item, the contractor shall consider the item as noncovered.For items that are dispensed based on a verbal order or preliminary written order, the supplier must obtain a detailed written order that meets the requirements of section 5.2.3 before submitting the claim.

Detailed Written Orders: Detailed written orders may take the form of a photocopy, facsimile image, electronically maintained, or original "pen-and-ink" document.  The written order must be sufficiently detailed, including all options or additional features that will be separately billed or that will require an upgraded code.  The description can be either a narrative description (e.g., lightweight wheelchair base) or a brand name/model number.  All orders must clearly specify the start date of the order.

  • If the written order is for supplies that will be provided on a periodic basis, the written order should include appropriate information on the quantity used, frequency of change, d duration of need.  For example, an order for surgical dressing might specify one 4 x 4 
    hydrocolloid dressing that is changed 1-2 times per week for 1 month or until the ulcer heals.
  • If the supply is a drug, the order must specify the name of the drug, concentration (if applicable), dosage, frequency of administration, and duration of infusion (if applicable).

Face-to-Face Encounter Requirements: For covered items a physician, a physician assistant (PA), a nurse practitioner (NP) or a clinical nurse specialist (CNS) must document that he/she has had a face-to-face encounter with the beneficiary within six (6) months prior to completing the written order. On claims selected for review if there is no documentation of a face-to-face encounter, contractors shall deny the claim when directed by CMS.

If the physician is not billing the E&M code and a PA, NP or CNS performed a face-to-face encounter for covered items consider billing the following G-Code;

G0454 - Physician documentation of face-to-face visit for durable medical equipment determination performed by nurse practitioner, physician assistant or clinical nurse specialist.

Reference:

- Medicare Program Integrity Manual Chapter 5 – Items and Services Having Special DME Review Considerations

###

Questions, comments?

If you have questions or comments about this article please contact us.  Comments that provide additional related information may be added here by our Editors.


Latest articles:  (any category)

Artificial Intelligence in Healthcare - A Medical Coder's Perspective
December 26th, 2023 - Aimee Wilcox
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities? 
Specialization: Your Advantage as a Medical Coding Contractor
December 22nd, 2023 - Find-A-Code
Medical coding contractors offer a valuable service to healthcare providers who would rather outsource coding and billing rather than handling things in-house. Some contractors are better than others, but there is one thing they all have in common: the need to present some sort of value proposition in order to land new clients. As a contractor, your value proposition is the advantage you offer. And that advantage is specialization.
ICD-10-CM Coding of Chronic Obstructive Pulmonary Disease (COPD)
December 19th, 2023 - Aimee Wilcox
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Changes to COVID-19 Vaccines Strike Again
December 12th, 2023 - Aimee Wilcox
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Updated ICD-10-CM Codes for Appendicitis
November 14th, 2023 - Aimee Wilcox
With approximately 250,000 cases of acute appendicitis diagnosed annually in the United States, coding updates were made to ensure high-specificity coding could be achieved when reporting these diagnoses. While appendicitis almost equally affects both men and women, the type of appendicitis varies, as dose the risk of infection, sepsis, and perforation.
COVID Vaccine Coding Changes as of November 1, 2023
October 26th, 2023 - Wyn Staheli
COVID vaccine changes due to the end of the PHE as of November 1, 2023 are addressed in this article.
Medicare Guidance Changes for E/M Services
October 11th, 2023 - Wyn Staheli
2023 brought quite a few changes to Evaluation and management (E/M) services. The significant revisions as noted in the CPT codebook were welcome changes to bring other E/M services more in line with the changes that took place with Office or Other Outpatient Services a few years ago. As part of CMS’ Medicare Learning Network, the “Evaluation and Management Services Guide” publication was finally updated as of August 2023 to include the changes that took place in 2023. If you take a look at the new publication (see references below),....



Home About Terms Privacy

innoviHealth® - 62 E 300 North, Spanish Fork, UT 84660 - Phone 801-770-4203 (9-5 Mountain)

Copyright © 2000-2024 innoviHealth Systems®, Inc. - CPT® copyright American Medical Association