Revised F2F examination and Written Order Prior to Delivery (WOPD) requirements for DME Items specified in Section 6407 of the Affordable Care Act (ACA)

The DME MAC's recently released a joint publication that provides clarification on who may perform the in-person visit and the responsibilities of the ordering physician.

The ACA contains provisions requiring that a physician verify that a F2F 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). The DMEPOS supplier must have documentation of both the F2F visit and completed Written Order Prior to Delivery (WOPD) in their file prior to the delivery of these items.

For the ordering practitioner prescribing a specified DME item:

• The F2F examination with the beneficiary must be conducted within the six (6) months prior to the date of the prescription
• The F2F 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 comprehensive medical record to demonstrate that the applicable coverage criteria are met
• The treating practitioner that conducted the F2F examination does not need to be the ordering practitioner for the DME item. However the ordering practitioner must:
• Verify that the in-person visit occurred within the 6-months prior to the date of their prescription, and
• Have documentation of the F2F examination that was conducted
• The ordering practitioner must provide a copy of the F2F examination and the WOPD for the item(s) to the DMEPOS supplier before the item can be delivered.

A date stamp (or similar) is required which clearly indicates the supplier’s date of receipt of both the F2F record and the completed WOPD with the ordering physician’s signature and signature date. It is recommended that both documents be separately date-stamped to avoid any confusion regarding the receipt date of these documents.

First Quarter Results of Prepayment Review for HCPCS code K0823 performed by the Jurisdiction D, DME MAC resulted in an overall potential improper payment rate of 63%

In the first quarter of 2014 the Jurisdiction D, DME MAC, Medical Review Department reviewed 265 claims for K0823 PWCs, of which 167 were denied resulting, based on dollars, in an overall potential improper payment rate of 63%.

The Top Denial Reasons cited include:

1. The documentation submitted does not support the beneficiary does not have sufficient upper extremity function to self-propel an optimally configured manual wheelchair.

Comments: The beneficiary's upper extremity limitations (weakness, coordination, ROM) that prevents the patient from self-propel an optimally-configured MWC to perform MRADLs during a typical day must be documented.

Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.

An optimally-configured manual wheelchair is one with an appropriate wheelbase, device weight, seating options, and other appropriate non-powered accessories.

2. The F2F examination submitted was incomplete or missing elements

Comments: For a power operated vehicle (POV) or power wheelchair (PWC) to be covered, the treating practitioner must conduct a F2F examination of the beneficiary before writing the order. The report should provide pertinent information about the following elements, but may include other details. Each element would not have to be addressed in every evaluation.

History of the present condition(s) and past medical history that is relevant to mobility needs

• Symptoms that limit ambulation
• Diagnoses that are responsible for these symptoms
• Progression of ambulation difficulty over time
• What ambulatory assistance (cane, walker, wheelchair, caregiver) is currently used and what has changed to now require the use of a power mobility device
• Physical examination that is relevant to mobility needs ( Weight)
• Cardiopulmonary examination if responsible for the mobility limitations
• Musculoskeletal examination – Including objective measurements of arm and leg strength and range of motion (if not provided in the therapist’s mobility evaluation)
• Neurological examination that indicates the beneficiary y is capable of safely operating a PMD and has not expressed an unwillingness to do so

3. The documentation submitted contained no detailed product description or the detailed product description submitted was invalid

Comments: Once the supplier has determined the specific power mobility device that is appropriate for the beneficiary based on the physician’s 7-element order, the supplier must prepare a written document (termed a detailed product description - DPD). Regardless of the form of the DPD, there must be sufficient detail to identify the item(s) in order to determine that the item(s) dispensed is properly coded.

The ordering physician must sign and date the DPD and the supplier must receive it prior to delivery of the PWC or POV. A date stamp or equivalent must be used to document the supplier receipt date.

4. The documentation submitted does not support the beneficiary’s mobility limitation cannot be sufficiently and safely resolved by the use of an appropriately fitted cane or walker.

Comments: The beneficiary's upper and lower extremity limitations (weakness, coordination, ROM) that prevents the patient from using an appropriately fitted cane or walker to perform MRADLs during a typical day must be documented.

Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper or lower extremities are relevant to the assessment of the beneficiary’s mobility limitations.

5. The 7 EO submitted was incomplete or missing elements. The 7 EO was not received by the supplier within 45 days after the completion of the F2F examination.

Comments: The 7 EO must contain all of the following elements:

• Beneficiary's Name
• Description of the item that is ordered. This may be general – e.g., "power operated vehicle", "power wheelchair", or "power mobility device"– or may be more specific.
• Date of the completion of the F2F examination
• Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
• Length of Need
• Ordering Practitioner's Signature
• Date of Ordering Practitioner's Signature

The 7 EO also must contain a legible identifier for the ordering practitioner and be date stamped on receipt.

It is a statutory requirement that all items of the 7 EO be entered specifically by and only by the practitioner who has conducted the face-to-face requirements.

Based on the results of this review, Noridian will continue with the K0823 Prepayment Review.