Face-to-Face Examination Requirements
What is a Face-to-Face Examination?
A face-to-face examination is an in-person or telehealth encounter between you (the treating practitioner) and your patient. This examination must be used to gather subjective and objective information specifically related to the medical condition requiring the ordered equipment or supplies.
When is a Face-to-Face Examination Required?
- A face-to-face examination is required for certain DMEPOS items as specified by Medicare
- The examination must occur within 6 months before the order date
- Some items, like Power Mobility Devices (PMDs), always require a face-to-face examination
- For oxygen therapy, a face-to-face exam must occur within 30 days prior to starting therapy
- Other items requiring a face-to-face exam will be published by CMS with 60 days’ notice
Documentation Requirements
Your medical record documentation must:
- Clearly relate to the specific equipment or supplies being ordered
- Include subjective and objective information about the relevant medical condition
- Support the medical necessity of the ordered items
- Be part of your standard medical record documentation
Documentation Examples
Your medical record should include relevant elements such as:
History
For Mobility Devices:
- Onset and duration of mobility limitations
- Impact on daily activities
- Previous interventions tried
- Falls history
- Home environment details
- Caregiver support available
For Respiratory Equipment:
- Breathing difficulties and symptoms
- Sleep problems or apnea symptoms
- Oxygen use history
- Smoking history
- Impact on activities of daily living
- Previous treatments tried
Physical Examination For Mobility Assessment:
- Muscle strength and range of motion
- Balance and coordination
- Gait analysis
- Transfer abilities
- Pain assessment
- Cognitive status affecting safe equipment use
For Respiratory Assessment:
- Respiratory rate and effort
- Breath sounds
- Oxygen saturation readings
- Exercise tolerance
- Signs of respiratory distress
- Use of accessory muscles
- Presence of edema
Progress Notes
- Changes in functional status or respiratory condition
- Response to previous interventions
- Safety concerns
- Goals and anticipated outcomes with equipment
- Results of relevant testing (pulmonary function tests, sleep studies, etc.)
Important Documentation Tips
- Use All Available Records: Medicare reviews the entire medical record. Include relevant documentation from:
- Physical/Occupational Therapists
- Respiratory Therapists
- Pulmonologists
- Sleep Medicine Specialists
- Other healthcare professionals involved in the patient’s care
- Keep Orders Clean: Do not include clinical information on prescriptions or orders. Medicare disregards clinical information written on orders when determining medical necessity. Keep all clinical documentation in the medical record.
- Addressing Documentation Gaps: You can add an addendum to your medical record to address minor documentation deficiencies when appropriate. The addendum should be dated and clearly labeled.
- Documentation Support: We provide guides with sample language to help ensure your documentation meets Medicare requirements. Contact us for:
- Condition-specific templates
- Documentation checklists
- Sample language guides
- Equipment-specific requirements
Standard Written Order (SWO) Requirements
What is a Standard Written Order?
A Standard Written Order (SWO), previously known as a Detailed Written Order (DWO), is your written communication to the DMEPOS supplier authorizing the equipment or supplies.
When is an SWO Required?
All DMEPOS items require an SWO for Medicare payment. Some items require the SWO before delivery (WOPD), while others can have the SWO completed before the claim is submitted.
Required Elements of an SWO
Every SWO must include:
- Beneficiary’s name or Medicare Beneficiary Identifier (MBI)
- General description of the item
- This can be a general description, brand name/model number, HCPCS code, or HCPCS code narrative
- For equipment: Include all separately billed options or accessories
- For supplies: Include all separately billed supplies
- Quantity to be dispensed (if applicable)
- Order date
- Treating practitioner’s name or National Provider Identifier (NPI)
- Treating practitioner’s signature
Important Notes About Orders
- The SWO must be completed before the supplier submits a claim to Medicare
- For items requiring a face-to-face examination, the SWO must be completed within 6 months of the face-to-face examination
- Keep a copy of the SWO in your medical records
- The SWO can be transmitted to the supplier electronically or in hard copy
