Citizens Memorial Healthcare - Bolivar, MO



MEDICARE FACE-TO-FACE REQUIREMENT EFFECTIVE 7/1/13Face to Face Encounter - The Physician, PA, NP or CNS must have a face-to-face encounter examination with the patient in the 6 months prior to the written order.Documentation - The face-to face encounter must document that the beneficiary was evaluated and/or treated for a condition that supports the need for the DME item.Physician Signature - If the face-to face is conducted by a PA, NP or CNS, a physician (MD or DO) must document the occurrence of the face to face by signing/co-signing and dating that portion of the medical record. The physician may bill for this using G0454.Written Order – This must include:Beneficiary’s nameItem of DME orderedPhysicians NPIPhysicians signatureDate of the orderItems affected and documentation that will be needed in the physicians face to face visit with the patient:Pressure support surfaces Group 1 - Gel or Solace MattressPatient is completely immobile ORPatient has limited mobility AND one or more of the following:Impaired nutritional status orFecal or urinary incontinence orAltered sensory perception orCompromised circulatory status ORPatient has one or more pressure ulcers on the trunk or pelvis AND one or more of the following conditions:Impaired nutritional status orFecal or urinary incontinence orAltered sensory perception orCompromised circulatory status ANDFor situations a, b, and c above the patient must have a care plan that is documented in the medical records that includes:Education of the patient and caregiver on the prevention and/or management of pressure ulcersRegular assessment by a nurse, physician or other licensed healthcare providerAppropriate turning and positioningAppropriate wound care Appropriate management of moisture/incontinenceNutritional assessment and invention consistent with the overall plan of care.Group 2 - Air MattressSituation APatient has multiple stage II pressure ulcers located on the trunk or pelvis (ICD-9 707.02 – 707.05) ANDPatient has been on a comprehensive ulcer treatment program for a minimum of 30 days, which included all of the following:Education of the patient and caregiver on the prevention and/or management of pressure ulcers; ANDRegular assessment by a nurse, physician or other licensed practitioner; ANDAppropriate turning and positioning; ANDAppropriate management of moisture/incontinence; ANDNutritional assessment and intervention consistent with the overall plan of care; ANDUse of an appropriate group 1 support surface ANDUlcers have worsened or remained the same over the past 30 days.Situation BLarge or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis (ICD-9 707.02 – 707.05).Situation CWithin the past 60 days myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (ICD-9 707.02-707.05) ANDPatient was discharged from a hospital or nursing facility within the past 30 days; ANDPatient was on a group 2 or 3 support surface immediately prior to the discharge.NOTE: Coverage is limited to 60 days from the date of surgery.Hospital Beds – 1 of the first 4 requirements must be documented along with the 5thPatient has a medical condition that requires positioning of the body in ways not feasible with an ordinary bed. Elevation of the head/upper body less than 30 degrees does not require the use of a hospital bed ORPatient requires positioning of the body in ways not feasible with an ordinary bed to alleviate pain ORPatient requires the head of the bed to be elevated more than 30 degress due to CHF, COPD or problems with aspiration. Pillows or wedges have been tried and failed. ORPatient requires traction equipment which can only be attached to a hospital bedANDPatient requires frequent changes in body position and/or has immediate need for change in body position.OxygenPatient has a severe lung disease or hypoxia-related symptoms that might be expected to improve with oxygen therapy ANDPatient has had a blood gas study that meets the criteria to qualify for oxygen that has been performed by the physician or a laboratory within 30 days prior to the oxygen order, or if performed in a hospital, within 2 days prior to the discharge date while the patient was in stable condition ANDPatient was seen and evaluated by the physician within 30 days prior to the oxygen being ordered ANDAlternative treatment measures have been tried or considered and deemed ineffective.Non-invasive VentilatorsContact Denee Blake at HME, 326-3584, if you have a patient you believe would benefit from a non-invasive ventilator and she will help you with what documentation is needed.Bi-papsContact Karen Kurtz at our Stephens office 326-2424 and she will help you with what documentation is needed.CpapsPhysician conducts a face-to-face clinical evaluation prior to the sleep study to assess the patient for OSA that is documented in a detailed narrative note in the patients chart. This evaluation should include pertinent information about the following elements (evaluation may include other details and each element would not have to be addressed in every evaluation):Signs and symptoms of sleep disordered breathing including snoring, daytime sleepiness, observed apneas, choking or gasping during sleep, morning headachesDuration of symptomsValidated sleep hygiene inventory such as the Epworth Sleepiness ScaleFocused cardiopulmonary and upper airway system evaluationNeck circumferenceBMIFor continued coverage beyond the 1st three months of therapy the patient must have a face to face visit with the physician in which the physician documents an improvement in the symptoms of OSA and adherence to use of the Cpap by review of the written report of the adherence data.NebulizersDocumentation must indicate the nebulizer is necessary to administer the following medications for the ICD-9 code indicated:Beta-adrenergics, anticholinergics, corticosteroids, and cromolyn for the management of obstructive pulmonary disease (ICD-9 diagnosis codes 491.0-505)Gentamicin, tobramycin, amikacin, or dornase alpha to a patient with cystic fibrosis (ICD-9 diagnosis code 277.02)Tobramycin to a patient with bronchiectasis (ICD-9 diagnosis code 494.0, 494.1, 748.61, 011.50-011.56)Pentamidine to patients with HIV (ICD-9 diagnosis code 042), pneumocystosis (ICD-9 diagnosis code 136.3), and complications of organ transplants (ICD-9 diagnosis codes 996.80-996.89)Mucolytics (other than dornase alpha) for persistent thick or tenacious pulmonary secretions (ICD-9 diagnosis codes 480.0-508.9,786.4)Blood glucose monitorsPatient has diabetes (ICD-9 250.00-250.93) which is being treated by the physicianThe monitor and supplies are ordered by the physician who is treating the patient’s diabetes and the physician maintains records reflecting care and records include the medical necessity for the prescribed frequency of testingPatient or caregiver has successfully completed training or is scheduled to begin training in the use of the monitor or suppliesPatient or caregiver is capable of using the test results to assure blood sugar control.If the patient is overtesting – Non-insulin dependent and testing more than once per day or insulin dependent and testing more than 3 times per day the notes must include the above information plus:Physician ordered the frequency of testing that exceeds utilization guidelines and has documentation in the medical record to support the need for this frequency of testing.Narrative statement which adequately documents the frequency at which the patient is actually testing.All of the blood glucose monitor documentation must be completed every 6 months by a patient face to face with the physician.Seat lift mechanismsPatient has arthritis of the hip or knee OR a severe neuromuscular disease and the physician is treating the patient for this condition.Seat lift mechanism is part of the physician’s course of treatment and is prescribed to effect improvement or arrest or retard deterioration of the patient’s condition.Patient must be incapable of standing up from any chair in their home.Once standing the patient must be able to ambulate.All appropriate therapeutic modalities (e.g. medication, physical therapy) have been tried and failed to enable the beneficiary to stand from a chair.A patient cannot have a wheelchair and a seat lift mechanism at the same time.Manual WheelchairsPatient has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home ANDThe mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker ANDUse of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the patient will use it on a regular basis in the home ANDPatient has not expressed an unwillingness to use the manual wheelchair that is provided in the home AND EITHERPatient has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day ORThe beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. ................
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