Documentation from the Face-to-Face Encounter

5.4.2 – Documentation from the Face-to-Face Encounter (Rev. 10190; Issued: 06-19-2020; Effective: 01-01-2020; Implementation: 07-01- 2020) A supplier must maintain the SWO and the supporting documentation provided by the treating practitioner and make them available to CMS and its contractors upon request. A supplier must submit additional documentation to CMS or its contractors, upon request, to support and/or substantiate the medical necessity for the DMEPOS. The face-to-face encounter must support payment and be documented in the pertinent portion of the medical record (for example, history, physical examination, diagnostic tests, summary of findings, progress notes, treatment plans or other sources of information that may be appropriate). The supporting documentation must include subjective and objective beneficiary specific information used for diagnosing, treating, or managing a clinical condition for which the DMEPOS is ordered. Section 1834(h)(5) of the Act states that for purposes of determining the reasonableness and medical necessity of orthotics and prosthetics, documentation created by orthotists and prosthetists shall be considered part of the individual’s medical record to support documentation created by eligible professionals as described in section 1848(k)(3)(B) of the Social Security Act. Documentation from a face-to-face encounter conducted by a treating practitioner, as well as documentation created by an orthotist or prosthetist, becomes part of the medical records. If the orthotist or prosthetist notes support the documentation created by eligible professionals described in section 1848(k)(3)(B), they can be used together to support medical necessity of an ordered DMEPOS item. In the event the orthotist or prosthetist documentation does not support the documentation created by the eligible professional, payment may be denied. If a supplier bills for an item listed on the Required Face-to-Face Encounter and Written Order Prior to Delivery List and does not possess documentation of the face-to-face encounter and/or the WOPD, the item will be denied.