Important Facts :
CMS expects that the patient’s medical records will reflect the need for the item ordered. The patient’s medical records include:
- Physician’s office records
- Hospital records
- Nursing home records
- Home health agency records
- Records from other healthcare professionals
- Test results
Other stipulations of the rule include:
- A prescription is not considered a part of the medical record.
- Supplier-produced records, even if signed by the ordering physician, and attestation letters are not considered by Medicare as part of the medical record.
- Templates and forms, including CMNs, are subject to corroboration with infor mation documented in the patient’s medical record.
- Only a physician can document that the face-to-face encounter occurred
- Signature and date stamps are not allowed
- Multiple items can be supported by a single face-to-face encounter, so long as each item’s medical necessity is documented in the patient’s medical record.
CMS has established a G-Code (G0454) to compensate physicians who document that a Physician’s Assistant, Nurse Practitioner, or Clinical Nurse Specialist performed the face-to-face encounter. This G-Code does not apply when a physician bills an evaluation and management code when the physician performs the face-to-face encounter himself/herself. The G-Codes may only be used when the physician documents a face-to-face encounter that is performed by a PA, NP or CNS.
If multiple orders for covered items originate from one face-to-face encounter, the physician is only eligible for the G-Code payment once.