Clarification on PMD orders

Questions answered by Medical Director Juristiction A

Subject: RE: Clarification on 7 element orders - 3 or 2 or 1 Help!!!

The first issue is: what is the face-to-face exam? Many suppliers and physician's seem to define it as only the in-person visit. The policy talks about it as having 2 elements (refer to the documentation section),

1. An in-person visit with the physician, and

2. A medical examination.

Both need to be done and documented. This concept gets confusing because folks separate the exam done by the physician and the PT/OT, (if one is done), and consider them as separate. For this LCD there are really 3 scenarios. All require an in-person visit to the doctor and only are different by how much of the medical exam is done and documented by the physician. They are:

1. The physician does it all and creates the report.

2. The physician does some parts of the exam and refers other to someone else (often a PT/OT) to do the rest. The physician prepares a report on their part and signs off on the referral exam.

3. The physician refers the exam. The referral does the exam and creates the report. The physician signs off on it.

The in-person visit AND the exam together comprise the face-to-face.

The face-to-face must be complete BEFORE the 7-element order is written. This requirement comes from the statute and we have published it in the Policy Article "Nonmedical Necessity Coverage and Payment Rules" section (which is where we put statutory requirements). It says,

"FACE-TO-FACE EXAMINATION:
For a power operated vehicle (POV) or power wheelchair (PWC) to be covered, the treating physician must conduct a face-to-face examination of the patient before writing the order and the supplier must receive a written report of this examination within 45 days after completion of the face-to-face examination and prior to delivery of the device. If this requirement is not met, the claim will be denied as non-covered. "

As I said before, I understand that many physicians want to write their prescriptions after their in-person visit. That is acceptable ONLY when they actually do the examination and create the report from their information. If they choose to refer the patient elsewhere fore an evaluation, they must wait until they receive that report. After receiving the report, they must indicate their acceptance of the findings and sign/date it. The date that is done becomes the date of the face-to-face exam and when complete THEN the 7-element order can be written.

Paul J. Hughes, MD
Medical Director
Jurisdiction A DME MAC
NHIC
75 Sgt. William B. Terry Drive
Hingham, MA 02043
803-359-2759