Round 2 of the competitive bidding program and the national mail-order program will go into effect July 1, 2013. Based on bids submitted by these suppliers, beneficiaries and Medicare will see prices, on average, 45 percent lower than Medicare currently pays for the same items included in the Round 2 areas and 72 percent lower on mail-order diabetic testing supplies nationwide.
Section 6407 of the Affordable Care Act (ACA) requires that a physician (MD, DO or DPM), physician assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS) has had a face-to-face examination with a beneficiary within the six (6) months prior to the written order for and delivery of certain items of DME.
A physician must verify that a face-to-face examination performed by a PA, NP or CNS was done within the 6 months prior to the creation of a prescription for the specified item(s)
Face-To-Face Examination Requirements
The physician must have a face-to-face examination with the beneficiary in the six (6) months prior to the date of the written order specified items of DME.
The DMEPOS supplier must have documentation of both the face-to-face visit and completed WOPD in their file prior to the delivery of these items.
For the physician prescribing a specified DME item:
The face-to-face examination with the beneficiary must be conducted within the six (6) months prior to the date of the prescription.
The face-to-face examination must document that the beneficiary was evaluated and/or treated for a condition that supports the need for the item(s) of DME ordered.
Remember that all Medicare coverage and documentation requirements for DMEPOS also apply. There must be sufficient medical information included in the medical record to demonstrate that the applicable coverage criteria are met. Refer to the applicable Local Coverage Determination for information about the medical necessity criteria for the item(s) being ordered.
The prescriber must provide a copy of the face-to-face examination and the prescription for the item(s) to the DMEPOS supplier before the item can be delivered.
Local Coverage Determinations (LCD)
LCDs that contain items subject to these requirements are:
Automatic External Defibrillators
Cervical Traction Devices
External Infusion Pumps
High-frequency Chest Wall Oscillation Devices
Home Glucose Monitors
Manual In-exsufflation Devices
Pneumatic Compression Devices
Positive Airway Pressure Devices
Power Mobility Devices
Pressure Reducing Support Surfaces – Group 1
Pressure Reducing Support Surfaces – Group 3
Respiratory Assist Devices
Seat Lift Mechanisms
Speech Generating Devices
Transcutaneous Electrical Nerve Stimulators (TENS)
Wheelchair options and Accessories