DME MAC Joint Publication
This FAQ is revised to update the criteria associated with the five-element written order prior to delivery (5EO) and face-to-face examination. While this document makes reference to “ACA 6407 requirements”, technically these requirements are found in the Social Security Act Section 1843(a)(11)(B) and its implementing regulation at 42 CFR 410.38. The CMS regulation contains the details for the face-to-face examination, written order prior to delivery and the list of items subject to these requirements.
As a condition for payment, Section 6407 of the ACA requires that a practitioner (MD, DO or DPM, PA, NP or CNS) has had a F2F examination with a beneficiary within the six months prior to the written order for certain items of DME (Refer to Table A for a list of items).
These ACA 6407 requirements are effective for claims for all of the specified items that require a new order on or after 7/1/2013. DME MAC enforcement of these rules related to the face-to-face examination requirement and face-to-face documentation is delayed until further notice from CMS. This face-to-face examination enforcement delay does not apply to the CERT program contractor. In addition, this delay in enforcement does not apply to the prescription requirements for a WOPD/5EO or to the requirement to include the prescriber’s NPI on the prescription.
ACA 6407 also contained a provision requiring that an MD or DO co-sign the face-to-face examination performed by a PA, NP or CNS. This requirement was eliminated by the MACRA of 2015.
A face-to-face examination is required each time a new prescription (i.e., written order) for one of the specified items in Table A is ordered. A new prescription is required by Medicare:
The first bullet above, claims for purchases or initial rentals, includes all claims for payment of purchases and initial rentals for items not originally covered (reimbursed) by Medicare Part B. Claims for items obtained outside of Medicare Part B, e.g. from another payer prior to Medicare participation (including Medicare Advantage plans), are considered to be new initial claims for Medicare payment purposes. This means that all Medicare payment requirements must be met, the same as any other item initially covered by Medicare.
ACA 6407 requires a specific written order prior to delivery for the HCPCS codes specified in Table A below. This ACA 6407-required prescription has five mandatory elements. The ACA 6407- required order is referred to as a 5EO. The 5EO must meet all of the requirements below:
Note that 5EO for these specified DME items require the NPI to be included on the prescription. Prescriptions for other DME items do not have this NPI requirement.
For items that are provided based on a 5EO, the supplier must obtain a detailed written order before submitting a claim for any associated options, accessories and/or supplies that are separately billed and not listed on the table below.
The 5EO must be available upon request.
For any of the specified items affected by the ACA 6407 requirements to be covered by Medicare, a written, signed and dated order (5EO) must be received by the supplier prior to delivery of the item. If the supplier delivers the item prior to receipt of a written order, it will be denied as statutorily noncovered. If the written order is not obtained prior to delivery, payment will not be made for that item even if a written order is subsequently obtained. If a similar item is subsequently provided by an unrelated supplier who has obtained a written order prior to delivery, it will be eligible for coverage.
Note that the 5EO for these specified DME items require the NPI of the prescribing practitioner. Prescriptions for other DME items do not have this NPI requirement. Suppliers should pay particular attention to orders that include a mix of items, some of which are subject to these new order requirements. For example, oxygen concentrators (E1390) are often ordered in conjunction with portable oxygen (E0431). Orders for code E0431 require inclusion of the NPI while orders for E1390 do not.
The treating practitioner must have a face-to-face examination with the beneficiary in the six months prior to the date of the written order for the specified items of DME.
This face-to-face requirement includes examinations conducted via the CMS-approved use of telehealth examinations (as described in Chapter 15 of the CMS Internet-Only Manual [IOM] Publication 100-08, Medicare Benefit Policy Manual and Chapter 12 of the CMS IOM Publication 100-04, Medicare Claims Processing Manual).
For the treat practitioner prescribing a specified DME item:
There are specific date and timing requirements:
All other date and timing requirements specified in the CMS IOM Publication 100-08, Medicare Program Integrity Manual regarding specific items or services remain unchanged.
Upon request by the contractor, all DMEPOS suppliers must provide documentation from the qualifying face-to-face examination and the completed 5EO.
A date stamp (or equivalent) is required which clearly indicates the supplier’s date of receipt of the completed 5EO.
Claims for the specified items subject to these face-to-face requirements and prescription requirements that do not meet the requirements specified above will be denied as statutorily noncovered - failed to meet statutory requirements.
LCDs that contain items subject to these requirements are:
These LCDs will be updated to include the requirements at a future date.
Numerous items are not included in a specific LCD. Some have coverage criteria described by National Coverage Determinations. Others have coverage determined on a case-by-case or individual-claim basis. This article and the associated CMS publications will constitute notice of these requirements for all of the applicable codes.
Refer to the applicable LCD, NCD and/or the supplier manual for additional information about 5EO requirements.
The DME list of Specified Covered Items is as follows. The original list was at 77 FR 44798. This original list contains some codes (codes marked with an “*”) that have been deleted or that were made not valid for Medicare while other codes (codes marked with an “**”) have had narrative changes. Updates to the list will be made as CMS releases revisions.
Refer to the Pricing, Data Analysis and Coding Contractor website for information on coding.
HCPCS Code | Description |
---|---|
E0185 | Gel or gel-like pressure mattress pad |
E0188 | Synthetic sheepskin pad |
E0189 | Lamb's wool sheepskin pad |
E0194 | Air fluidized bed |
E0197 | Air pressure pad for mattress standard length and width |
E0198 | Water pressure pad for mattress standard length and width |
E0199 | Dry pressure pad for mattress standard length and width |
E0250 | Hospital bed fixed height with any type of side rails, mattress |
E0251 | Hospital bed fixed height with any type side rails without mattress |
E0255 | Hospital bed variable height with any type side rails with mattress |
E0256 | Hospital bed variable height with any type side rails without mattress |
E0260 | Hospital bed semi-electric (Head and foot adjustment) with any type side rails with mattress |
E0261 | Hospital bed semi-electric (head and foot adjustment) with any type side rails without mattress |
E0265 | Hospital bed total electric (head, foot and height adjustments) with any type side rails with mattress |
E0266 | Hospital bed total electric (head, foot and height adjustments) with any type side rails without mattress |
E0290 | Hospital bed fixed height without rails with mattress |
E0291 | Hospital bed fixed height without rail without mattress |
E0292 | Hospital bed variable height without rail without mattress |
E0293 | Hospital bed variable height without rail with mattress |
E0294 | Hospital bed semi-electric (head and foot adjustment) without rail with mattress |
E0295 | Hospital bed semi-electric (head and foot adjustment) without rail without mattress |
E0296 | Hospital bed total electric (head, foot and height adjustments) without rail with mattress |
E0297 | Hospital bed total electric (head, foot and height adjustments) without rail without mattress |
E0300 | Pediatric crib, hospital grade, fully enclosed |
E0301 | Hospital bed heavy duty extra wide, with weight capacity 350–600 lbs with any type of rail, without mattress |
E0302 | Hospital bed heavy duty extra wide, with weight capacity greater than 600 lbs with any type of rail, without mattress |
E0303 | Hospital bed heavy duty extra wide, with weight capacity 350–600 lbs with any type of rail, with mattress |
E0304 | Hospital bed heavy duty extra wide, with weight capacity greater than 600 lbs with any type of rail, with mattress |
E0424 | Stationary compressed gas oxygen system rental; includes contents, regulator, nebulizer, cannula or mask and tubing |
E0431 | Portable gaseous oxygen system rental includes portable container, regulator, flowmeter, humidifier, cannula or mask, and tubing |
E0433 | Portable liquid oxygen system |
E0434 | Portable liquid oxygen system, rental; includes portable container, supply reservoir, humidifier, flowmeter, refill adaptor, content gauge, cannula or mask, and tubing |
E0439 | Stationary liquid oxygen system rental, includes container, contents, regulator, flowmeter, humidifier, nebulizer, cannula or mask, and tubing |
E0441 | Oxygen contents, gaseous (one month’s supply) |
E0442 | Oxygen contents, liquid (one month’s supply) |
E0443 | Portable oxygen contents, gas (one month’s supply) |
E0444 | Portable oxygen contents, liquid (one month’s supply) |
E0450* | Volume control ventilator without pressure support used with invasive interface |
E0460* | Negative pressure ventilator portable or stationary |
E0461* | Volume control ventilator without pressure support node for a noninvasive interface |
E0462 | Rocking bed with or without side rail |
E0463* | Pressure support ventilator with volume control mode used for invasive surfaces |
E0464* | Pressure support vent with volume control mode used for noninvasive surfaces |
E0470 | Respiratory assist device, bi-level pressure capability, without backup rate used noninvasive interface |
E0471 | Respiratory assist device, bi-level pressure capability, with backup rate for a noninvasive interface |
E0472 | Respiratory assist device, bi-level pressure capability, with backup rate for invasive interface |
E0480 | Percussor electric/pneumatic home model |
E0482 | Cough stimulating device, alternating positive and negative airway pressure |
E0483 | High Frequency chest wall oscillation air pulse generator system |
E0484 | Oscillatory positive expiratory device, nonelectric |
E0570 | Nebulizer with compressor |
E0575 | Nebulizer, ultrasonic, large volume |
E0580 | Nebulizer, durable, glass or autoclavable plastic, bottle type for use with regulator or flowmeter |
E0585 | Nebulizer with compressor and heater |
E0601 | Continuous airway pressure device |
E0607 | Home blood glucose monitor |
E0627 | Seat lift mechanism incorporated lift-chair |
E0628 | Separate Seat lift mechanism for patient owned furniture electric |
E0629 | Separate seat lift mechanism for patient owned furniture non-electric |
E0636 | Multi positional patient support system, with integrated lift, patient accessible controls |
E0650 | Pneumatic compressor non-segmental home model |
E0651 | Pneumatic compressor segmental home model without calibrated gradient pressure |
E0652 | Pneumatic compressor segmental home model with calibrated gradient pressure |
E0655 | Nonsegmental pneumatic appliance for use with pneumatic compressor on half arm |
E0656 | Nonsegmental pneumatic appliance for use with pneumatic compressor on trunk |
E0657 | Nonsegmental pneumatic appliance for use with pneumatic compressor chest |
E0660 | Nonsegmental pneumatic appliance for use with pneumatic compressor on full leg |
E0665 | Nonsegmental pneumatic appliance for use with pneumatic compressor on full arm |
E0666 | Nonsegmental pneumatic appliance for use with pneumatic compressor on half leg |
E0667 | Segmental pneumatic appliance for use with pneumatic compressor on full-leg |
E0668 | Segmental pneumatic appliance for use with pneumatic compressor on full arm |
E0669 | Segmental pneumatic appliance for use with pneumatic compressor on half leg |
E0671 | Segmental gradient pressure pneumatic appliance full leg |
E0672 | Segmental gradient pressure pneumatic appliance full arm |
E0673 | Segmental gradient pressure pneumatic appliance half leg |
E0675 | Pneumatic compression device, high pressure, rapid inflation/deflation cycle, for arterial insufficiency |
E0692 | Ultraviolet light therapy system panel treatment 4 foot panel |
E0693 | Ultraviolet light therapy system panel treatment 6 foot panel |
E0694 | Ultraviolet multidirectional light therapy system in 6 foot cabinet |
E0720 | Transcutaneous electrical nerve stimulation, two lead, local stimulation |
E0730 | Transcutaneous electrical nerve stimulation, four or more leads, for multiple nerve stimulation |
E0731 | Form fitting conductive garment for delivery of TENS or NMES |
E0740 | Incontinence treatment system, Pelvic floor stimulator, monitor, sensor, and/or trainer |
E0744 | Neuromuscular stimulator for scoliosis |
E0745 | Neuromuscular stimulator electric shock unit |
E0747 | Osteogenesis stimulator, electrical, noninvasive, other than spine application. |
E0748 | Osteogenesis stimulator, electrical, noninvasive, spinal application |
E0749 | Osteogenesis stimulator, electrical, surgically implanted |
E0760 | Osteogenesis stimulator, low intensity ultrasound, noninvasive |
E0762 | Transcutaneous electrical joint stimulation system including all accessories |
E0764 | Functional neuromuscular stimulator, transcutaneous stimulations of muscles of ambulation with computer controls |
E0765 | FDA approved nerve stimulator for treatment of nausea and vomiting |
E0782 | Infusion pumps, implantable, Nonprogrammable |
E0783 | Infusion pump, implantable, programmable |
E0784 | External ambulatory infusion pump |
E0786 | Implantable programmable infusion pump, replacement |
E0840 | Tract frame attach to headboard, cervical traction |
E0849 | Traction equipment cervical, free-standing stand/frame, pneumatic, applying traction force to other than mandible |
E0850 | Traction stand, free standing, cervical traction |
E0855 | Cervical traction equipment not requiring additional stand or frame |
E0856 | Cervical traction device, cervical collar with inflatable air bladder |
E0958** | Manual wheelchair accessory, one-arm drive attachment |
E0959** | Manual wheelchair accessory-adapter for Amputee |
E0960** | Manual wheelchair accessory, shoulder harness/strap |
E0961** | Manual wheelchair accessory wheel lock brake extension handle |
E0966** | Manual wheelchair accessory, headrest extension |
E0967** | Manual wheelchair accessory, hand rim with projections |
E0968* | Commode seat, wheelchair |
E0969* | Narrowing device wheelchair |
E0971** | Manual wheelchair accessory anti-tipping device |
E0973** | Manual wheelchair accessory, adjustable height, detachable armrest |
E0974** | Manual wheelchair accessory anti-rollback device |
E0978* | Manual wheelchair accessory positioning belt/safety belt/ pelvic strap |
E0980* | Manual wheelchair accessory safety vest |
E0981** | Manual wheelchair accessory Seat upholstery, replacement only |
E0982** | Manual wheelchair accessory, back upholstery, replacement only |
E0983** | Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, joystick control |
E0984** | Manual wheelchair accessory power add on to convert manual wheelchair to motorized wheelchair, Tiller control |
E0985 | Wheelchair accessory, seat lift mechanism |
E0986** | Manual wheelchair accessory, push activated power assist |
E0990** | Manual wheelchair accessory, elevating leg rest |
E0992** | Manual wheelchair accessory, elevating leg rest solid seat insert |
E0994* | Arm rest |
E1014 | Reclining back, addition to pediatric size wheelchair |
E1015 | Shock absorber for manual wheelchair |
E1020 | Residual limb support system for wheelchair |
E1028** | Wheelchair accessory, manual swing away, retractable or removable mounting hardware for joystick, other control interface or positioning accessory |
E1029** | Wheelchair accessory, ventilator tray |
E1030** | Wheelchair accessory, ventilator tray, gimbaled |
E1031 | Rollabout chair, any and all types with castors 5” or greater |
E1035** | Multi-positional patient transfer system with integrated seat operated by care giver |
E1036** | Patient transfer system |
E1037 | Transport chair, pediatric size |
E1038** | Transport chair, adult size up to 300lb |
E1039** | Transport chair, adult size heavy duty > 300lb |
E1161 | Manual Adult size wheelchair includes tilt in space |
E1227* | Special height arm for wheelchair |
E1228* | Special back height for wheelchair |
E1232 | Wheelchair, pediatric size, tilt-in-space, folding, adjustable with seating system |
E1233** | Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system |
E1234 | Wheelchair, pediatric size, tilt-in-space, folding, adjustable without seating system |
E1235 | Wheelchair, pediatric size, rigid, adjustable, with seating system |
E1236 | Wheelchair, pediatric size, folding, adjustable, with seating system |
E1237 | Wheelchair, pediatric size, rigid, adjustable, without seating system |
E1238 | Wheelchair, pediatric size, folding, adjustable, without seating system |
E1296* | Special sized wheelchair seat height |
E1297* | Special sized wheelchair seat depth by upholstery |
E1298* | Special sized wheelchair seat depth and/or width by construction |
E1310** | Whirlpool nonportable |
E2502** | Speech Generating Devices prerecord messages between 8 and 20 Minutes |
E2506** | Speech Generating Devices prerecord messages over 40 minutes |
E2508** | Speech Generating Devices message through spelling, manual type |
E2510** | Speech Generating Devices synthesized with multiple message methods |
E2227** | Rigid pediatric wheelchair adjustable |
K0001 | Standard wheelchair |
K0002 | Standard hemi (low seat) wheelchair |
K0003 | Lightweight wheelchair |
K0004 | High strength lightweight wheelchair |
K0005 | Ultra-lightweight wheelchair |
K0006 | Heavy duty wheelchair |
K0007 | Extra heavy duty wheelchair |
K0009 | Other manual wheelchair/base |
K0606** | Automated external defibrillators (AED) garment with electronic analysis |
K0730 | Controlled dose inhalation drug delivery system |
Revised Posting Date: April 28, 2016
Revised Posting Date: 10/1/2015
Revised Posting Date: 5/29/2014
Original Posted Date: 2/21/2014