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Physicians face new rules for durable medical equipment orders


There are times when a practice needs to order supplies for patients through a Durable Medical Equipment (DME) provider. But there has been some recent changes to these rules.


Renee StantzThere are times when our practice needs to order supplies for patients through a Durable Medical Equipment (DME) provider. We heard there were some recent changes to these rules. Do the changes affect the ordering physician?

Most physician offices probably didn’t take notice of the requirements, thinking they only affected the DME provider. However, they also affect the ordering physician.

The new regulation is detailed in Medicare’s Learning Network (MLN) Matters Number MM8304, updated June 28, 2013. 

MM803 reads: “The law requires that a physician must document that a physician, nurse practitioner (NP), physician assistant (PA) or clinical nurse specialist (CNS) has had a face-to-face encounter with the patient. The encounter must occur within the six months before the order is written for the DME.”

The date of the written order must not be prior to the date of the face-to-face encounter, and the face-to-face encounter must document that the beneficiary was evaluated and/or treated for a condition that supports the DME item(s) ordered. The Centers for Medicare and Medicaid Services (CMS) believes this new requirement will reduce the risk of fraud, waste, and abuse since these visits help ensure a patient’s condition warrants the DME item.

During the face-to-face encounter, the physician or other qualified healthcare professional must evaluate the patient, conduct a needs assessment, and/or treat the patient for the medical condition that supports the need for each covered DME item. Documentation in the medical record must include the identity of the practitioner who provided the face-to-face assessment. A written order is required for covered DME items.

The CMS Program Integrity Manual, Chapter 5, Section 5.2.3 (which can be found at CMS Internet-Only Manuals) delineates the minimum information that the order must contain:

  • beneficiary’s name;

  • item of DME ordered;

  • prescribing practitioner’s National Provider Identifier (NPI);

  • signature of the ordering practitioner; and

  • date of the order.

Failure to meet the requirements will result in denial of the claim.

This requirement is only for certain DME items. The list of items can be found as Appendix A at the end of MLN Matters MM8304. Medicare covers certain types of medical equipment such as walkers, wheelchairs, hospital beds, home oxygen equipment, diabetes self-testing equipment and supplies, respiratory assist devices, infusion pumps, oxygen equipment, prosthetics, orthotics and supplies.

When a DME item is ordered by a PA, NP, or CNS, a physician must document the occurrence of a face-to-face encounter by signing and dating the pertinent portion of the medical record. CMS will accept a single confirming signature, including the date, as sufficient if there are several pertinent portions of the medical record.

Physicians who do not bill the evaluation and management code for the beneficiary are eligible to bill the new HCPCS Level II code G0454, which is used to document that a PA, NP or CNS has performed a face-to-face encounter for specified covered items.


The answer to our reader’s question was provided by Renee Stantz, a billing and coding consultant with VEI Consulting Services in Indianapolis, Indiana. Send your practice management questions to medec@advanstar.com.


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