Washington Wit & Wisdom
Facing the Facts
More than three years after the Patient Protection and Affordable Care Act (PPACA, or the Health Reform Law) was signed into law by President Obama, the Centers for Medicare & Medicaid Services (CMS) issued its proposed rule to begin implementing Section 6407 of that law which requires beneficiaries to have a “face-to-face” encounter prior to a physician prescribing durable medical equipment (DME). The law requires physicians to document that a physician, physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS) has had a face-to-face encounter with the beneficiary within six months preceding the written order for the DME, or other reasonable timetable the secretary may determine.
On July 10, 2012, CMS issued its proposed rule in the Federal Register. It was part of a larger proposed rule largely covering 2013 physician payment policy revisions. As a condition of payment for many DME items, the proposed rule will require that a physician, PA, NP or CNS has had a face-to-face encounter with the beneficiary. This encounter must be documented by the physician and communicated to the DME provider. Under the proposal, the encounter must occur no more than 90 days before the written order or 30 days after the order is written.
Comments on the proposed rule are due on September 4, 2012. CMS is likely to issue a final rule by November 1, 2012, and have an effective date for the new requirement for DME items provided on or after January 1, 2013. It is important for HME providers to understand all the requirements of the proposal, and based on the forthcoming CMS final rule, identify additional policies and procedures to implement and train staff on to ensure compliance with the new rule by January 2013.
Items Subject to the Exam Requirement
CMS is proposing four criteria that would subject DME items to the face-to-face requirement:
A. DME that currently require a written order prior to delivery as defined by CMS in its Program Integrity Manual; the PIM identifies pressure reducing pads, mattress overlays, mattresses, and beds; seat lift mechanisms; transcutaneous electrical nerve stimulation (TENS) units; power operated vehicles (POV); and power wheelchairs.
B. DME with a Medicare fee schedule ceiling of more than $1,000.
C. Items that CMS, based on recommendations from the DME MACs, believes are particularly susceptible to fraud, waste and abuse. The DME MACs recommended the following items warrant increased practitioner involvement because they are often marketed directly to beneficiaries:
• Pressure reducing pads;
• Mattress overlays, mattresses and beds;
• Seat lift mechanisms;
• TENS units;
• Automatic external defibrillators (AED);
• External infusion pumps;
• Glucose monitors;
• Wheelchairs and wheelchair accessories;
• Negative pressure wound therapy (NPWT) pumps;
• Oxygen and oxygen equipment;
• Pneumatic compression devices;
• Positive airway pressure devices;
• Respiratory assists devices, and;
• Cervical traction devices.
D. DME CMS determines is vulnerable to fraud, waste and abuse based on reports of the HHS Office of Inspector General (OIG), Government Accountability Office (GAO) or other government oversight entities. CMS provides three such examples: pressure reducing support surfaces, home oxygen therapy, and negative pressure wound therapy.
CMS proposes a list of 164 DME HCPCS codes (see sidebar) that CMS believes will reduce the risk of fraud, waste and abuse. This list would be published and updated annually in the Federal Register and would appear on the CMS website. The list contains DME and not prosthetics and orthotics because, according to CMS, these DME items are often marketed directly to beneficiaries and the face-to-face encounter will help ensure ordering physicians are familiar with and document the beneficiary’s medical condition and that the items are reasonable and necessary.