does Medicare require doctor visits every 6 months?

I ordered the regular supplies (face mask cushion, tubing, etc) and the next day I got a call from the doctor who prescribed the CPAP machine more than 2 years ago telling me that I need to come for a visit in order for the supplies order to get through (“Medicare requirement” I was told). I am on my 3rd CPAP machine in 15 years and I never had to go to the CPAP prescribing doctor in order to have my supply order go through. So I went to the doctor and he told me that I have to come every 6 months.
Is there such a requirement by Medicare?

Here are the Medicare requirements for CPAP....
https://www.cms.gov/Outreach-and-Educat ... 905064.pdf

You might want to check out this thread.viewtopic.php?f=1&t=109738&p=1048353#p1048353
Medicare changed some rules 11-10-15. Sonnyboy posted a link to the changes. https://www.cms.gov/Regulations-and-Gui ... m83c05.pdf The changes are in red. I think the enforcement is just beginning and it probably depends on who you have for DME.

LSAT thanks. The only related mention I found in the document is For long-term PAP therapy, documentation from the supplier or physician must support that
the patient continues to use the PAP device. No specifics about the documentation required or the frequency.

OkyDoky thanks. It looks like a waste of money by Medicare and Medigap insurers.

drdigital1 wrote:LSAT thanks. The only related mention I found in the document is For long-term PAP therapy, documentation from the supplier or physician must support that
the patient continues to use the PAP device. No specifics about the documentation required or the frequency.

Ask your doctor's office to show you where in the regulations are you required to have a 6 month (or even annual) visit to continue supplies for a diagnosis that has already been made. If they want you (or your insurance company or medicare) to shell out several hundred dollars more annually, then they better have a justification for it. If they can't give you the info, consider contacting Medicare's fraud unit and explain that you want to comply with Medicare's requirements, but this doesn't make any sense.

I personally think that the doctor's office has wrongly interpreted the change below. Maybe they lack the comprehension skills as this refers to the original order. You can't have a sleep study in January and then get a prescription for an initial machine 7 months later.

The date of the face face examination must be on or before the date of the written order (prescription) and may be no older than 6 months prior to the prescription date.

BTW, documentation for continued use is your SD card. My DME (Lincare) has already said that I can turn off the modem after the rental period is complete. If additional documentation is needed by Medicare later on, they will either get it from the doctor's office OR have me turn the modem back on and obtain it directly from the upload or by bringing in SD card. This just shows that you are continuing to use the medical device, thus justifying the need for supplies.

SewTired thanks.
I'll start by questioning the DME since the sequence was:
1. I called the DME where I have been ordering supplies for the last 2 years and placed a new order.
2. I then got the call from the doctor who said that for the order to be filled I must come for a visit. And during the visit he said I needed to come every 6 months.
So it was the DME who initiated the contact with the doctor. I'll ask them how often is this needed and why is this necessary in the first place.

drdigital1 wrote:I ordered the regular supplies (face mask cushion, tubing, etc) and the next day I got a call from the doctor who prescribed the CPAP machine more than 2 years ago telling me that I need to come for a visit in order for the supplies order to get through (“Medicare requirement” I was told). I am on my 3rd CPAP machine in 15 years and I never had to go to the CPAP prescribing doctor in order to have my supply order go through. So I went to the doctor and he told me that I have to come every 6 months.
Is there such a requirement by Medicare?

I copied this from the link provided by OkyDoky: 5.2.5 - Face-to-Face Encounter Requirements
(Rev. 617, Issued: 10-09-15: Effective: 11-10-15, Implementation: 11-10-15)
This section only applies to covered items as defined in 42 CFR 410.38(g). CMS will
notify contractors of any annual updates to the list of covered items. CMS will notify the
public of any updates in the list of covered items via the Federal Register. Contractors
shall not apply this section to PMDs.
For covered items as defined in 42 CFR 410.38(g) a physician, a physician assistant
(PA), a nurse practitioner (NP) or a clinical nurse specialist (CNS) must document
that he/she has had a face-to-face encounter with the beneficiary within six (6) months
prior to completing the written order. On claims selected for review if there is no
documentation of a face-to-face encounter, contractors shall deny the claim when
directed by CMS.

With the physician I work with we require the patient's to come in once a year for a face to face evaluation. We download the CPAP and record that the patient is compliant, address any problems and proved another prescription for the next year. We've done this with DME companies since November forward and patient's seem to be receiving their supplies fine when needed. However, I am a little worried as if I read this correctly Medicare could start denying coverage if the patient does not have a corresponding face to face note dated within six months of the order being provided. So, if this reads correctly it looks that the rule has been changed to every six months and your provider is correct? Anyone else read this differently?

thecpapguy! wrote:

drdigital1 wrote:I ordered the regular supplies (face mask cushion, tubing, etc) and the next day I got a call from the doctor who prescribed the CPAP machine more than 2 years ago telling me that I need to come for a visit in order for the supplies order to get through (“Medicare requirement” I was told). I am on my 3rd CPAP machine in 15 years and I never had to go to the CPAP prescribing doctor in order to have my supply order go through. So I went to the doctor and he told me that I have to come every 6 months.
Is there such a requirement by Medicare?

I copied this from the link provided by OkyDoky: 5.2.5 - Face-to-Face Encounter Requirements
(Rev. 617, Issued: 10-09-15: Effective: 11-10-15, Implementation: 11-10-15)
This section only applies to covered items as defined in 42 CFR 410.38(g). CMS will
notify contractors of any annual updates to the list of covered items. CMS will notify the
public of any updates in the list of covered items via the Federal Register. Contractors
shall not apply this section to PMDs.
For covered items as defined in 42 CFR 410.38(g) a physician, a physician assistant
(PA), a nurse practitioner (NP) or a clinical nurse specialist (CNS) must document
that he/she has had a face-to-face encounter with the beneficiary within six (6) months
prior to completing the written order. On claims selected for review if there is no
documentation of a face-to-face encounter, contractors shall deny the claim when
directed by CMS.

With the physician I work with we require the patient's to come in once a year for a face to face evaluation. We download the CPAP and record that the patient is compliant, address any problems and proved another prescription for the next year. We've done this with DME companies since November forward and patient's seem to be receiving their supplies fine when needed. However, I am a little worried as if I read this correctly Medicare could start denying coverage if the patient does not have a corresponding face to face note dated within six months of the order being provided. So, if this reads correctly it looks that the rule has been changed to every six months and your provider is correct? Anyone else read this differently?

I have been looking at 42 CFR 410.38 and it appears to be addressing the larger DME equipnent so I'm not sure that this would apply to CPAP but look at the link that Sonnyboy posted where I copied this from. https://www.cms.gov/Regulations-and-Gui ... m83c05.pdf

thecpapguy! wrote:

drdigital1 wrote:I ordered the regular supplies (face mask cushion, tubing, etc) and the next day I got a call from the doctor who prescribed the CPAP machine more than 2 years ago telling me that I need to come for a visit in order for the supplies order to get through (“Medicare requirement” I was told). I am on my 3rd CPAP machine in 15 years and I never had to go to the CPAP prescribing doctor in order to have my supply order go through. So I went to the doctor and he told me that I have to come every 6 months.
Is there such a requirement by Medicare?

I copied this from the link provided by OkyDoky: 5.2.5 - Face-to-Face Encounter Requirements
(Rev. 617, Issued: 10-09-15: Effective: 11-10-15, Implementation: 11-10-15)
This section only applies to covered items as defined in 42 CFR 410.38(g). CMS will
notify contractors of any annual updates to the list of covered items. CMS will notify the
public of any updates in the list of covered items via the Federal Register. Contractors
shall not apply this section to PMDs.
For covered items as defined in 42 CFR 410.38(g) a physician, a physician assistant
(PA), a nurse practitioner (NP) or a clinical nurse specialist (CNS) must document
that he/she has had a face-to-face encounter with the beneficiary within six (6) months
prior to completing the written order. On claims selected for review if there is no
documentation of a face-to-face encounter, contractors shall deny the claim when
directed by CMS.

With the physician I work with we require the patient's to come in once a year for a face to face evaluation. We download the CPAP and record that the patient is compliant, address any problems and proved another prescription for the next year. We've done this with DME companies since November forward and patient's seem to be receiving their supplies fine when needed. However, I am a little worried as if I read this correctly Medicare could start denying coverage if the patient does not have a corresponding face to face note dated within six months of the order being provided. So, if this reads correctly it looks that the rule has been changed to every six months and your provider is correct? Anyone else read this differently?

While I can't speak for your physician, as a sleep doc myself I would point you to look specifically at the list of items covered by the rule. Specifically it is only PAP devices which are subject to the 6 month rule. PAP Supplies (specifically any of the HCPCS codes for masks, tubing, filters, etc) are not mentioned in the specific list of DME items that are subject to the face to face rule. Therefore I believe that unless you are getting a new machine, you should be able to have supplies refilled without a face to face encounter.

That being said, the script likely would need to be renewed on an annual basis. While your provider could do this without seeing you, I typically prefer seeing patients on an annual basis as well to ensure that there are no changes to therapy as a lot can happen in a years time.

OkyDoky wrote:

thecpapguy! wrote:

drdigital1 wrote:I ordered the regular supplies (face mask cushion, tubing, etc) and the next day I got a call from the doctor who prescribed the CPAP machine more than 2 years ago telling me that I need to come for a visit in order for the supplies order to get through (“Medicare requirement” I was told). I am on my 3rd CPAP machine in 15 years and I never had to go to the CPAP prescribing doctor in order to have my supply order go through. So I went to the doctor and he told me that I have to come every 6 months.
Is there such a requirement by Medicare?

I copied this from the link provided by OkyDoky: 5.2.5 - Face-to-Face Encounter Requirements
(Rev. 617, Issued: 10-09-15: Effective: 11-10-15, Implementation: 11-10-15)
This section only applies to covered items as defined in 42 CFR 410.38(g). CMS will
notify contractors of any annual updates to the list of covered items. CMS will notify the
public of any updates in the list of covered items via the Federal Register. Contractors
shall not apply this section to PMDs.
For covered items as defined in 42 CFR 410.38(g) a physician, a physician assistant
(PA), a nurse practitioner (NP) or a clinical nurse specialist (CNS) must document
that he/she has had a face-to-face encounter with the beneficiary within six (6) months
prior to completing the written order. On claims selected for review if there is no
documentation of a face-to-face encounter, contractors shall deny the claim when
directed by CMS.

With the physician I work with we require the patient's to come in once a year for a face to face evaluation. We download the CPAP and record that the patient is compliant, address any problems and proved another prescription for the next year. We've done this with DME companies since November forward and patient's seem to be receiving their supplies fine when needed. However, I am a little worried as if I read this correctly Medicare could start denying coverage if the patient does not have a corresponding face to face note dated within six months of the order being provided. So, if this reads correctly it looks that the rule has been changed to every six months and your provider is correct? Anyone else read this differently?

I have been looking at 42 CFR 410.38 and it appears to be addressing the larger DME equipnent so I'm not sure that this would apply to CPAP but look at the link that Sonnyboy posted where I copied this from. https://www.cms.gov/Regulations-and-Gui ... m83c05.pdf

Check here: https://www.cms.gov/Research-Statistics ... pment.html

It links to the list which has PAP devices on the list, however I don't see pap supplies on the list.

OkyDoky wrote:

thecpapguy! wrote:

drdigital1 wrote:I ordered the regular supplies (face mask cushion, tubing, etc) and the next day I got a call from the doctor who prescribed the CPAP machine more than 2 years ago telling me that I need to come for a visit in order for the supplies order to get through (“Medicare requirement” I was told). I am on my 3rd CPAP machine in 15 years and I never had to go to the CPAP prescribing doctor in order to have my supply order go through. So I went to the doctor and he told me that I have to come every 6 months.
Is there such a requirement by Medicare?

I copied this from the link provided by OkyDoky: 5.2.5 - Face-to-Face Encounter Requirements
(Rev. 617, Issued: 10-09-15: Effective: 11-10-15, Implementation: 11-10-15)
This section only applies to covered items as defined in 42 CFR 410.38(g). CMS will
notify contractors of any annual updates to the list of covered items. CMS will notify the
public of any updates in the list of covered items via the Federal Register. Contractors
shall not apply this section to PMDs.
For covered items as defined in 42 CFR 410.38(g) a physician, a physician assistant
(PA), a nurse practitioner (NP) or a clinical nurse specialist (CNS) must document
that he/she has had a face-to-face encounter with the beneficiary within six (6) months
prior to completing the written order. On claims selected for review if there is no
documentation of a face-to-face encounter, contractors shall deny the claim when
directed by CMS.

With the physician I work with we require the patient's to come in once a year for a face to face evaluation. We download the CPAP and record that the patient is compliant, address any problems and proved another prescription for the next year. We've done this with DME companies since November forward and patient's seem to be receiving their supplies fine when needed. However, I am a little worried as if I read this correctly Medicare could start denying coverage if the patient does not have a corresponding face to face note dated within six months of the order being provided. So, if this reads correctly it looks that the rule has been changed to every six months and your provider is correct? Anyone else read this differently?

I have been looking at 42 CFR 410.38 and it appears to be addressing the larger DME equipnent so I'm not sure that this would apply to CPAP but look at the link that Sonnyboy posted where I copied this from. https://www.cms.gov/Regulations-and-Gui ... m83c05.pdf

Medicare is always so confusing OkyDoky. I may have to put a call in to get definitive information. To me I initially thought that the six months this provider was required was no correct, but it looks that they may be. Here is another portion: 5.2.6 - Date and Timing Requirements
(Rev. 617, Issued: 10-09-15: Effective: 11-10-15, Implementation: 11-10-15)
For items outlined in 42 CFR 410.38 (g), the following specific date and timing
requirements apply:
• The date of the face-to-face examination must be on or before the date of the
written order (prescription) and may be no older than 6 months prior to the
prescription date.
• The date of the face-to-face examination must be on or before the date of delivery
for the item (s) prescribed.
• The date of the written order must be on or before the date of delivery.
• The DMEPOS supplier must have documentation of both the face-to-fac

drdigital1 wrote:SewTired thanks.
I'll start by questioning the DME since the sequence was:
1. I called the DME where I have been ordering supplies for the last 2 years and placed a new order.
2. I then got the call from the doctor who said that for the order to be filled I must come for a visit. And during the visit he said I needed to come every 6 months.
So it was the DME who initiated the contact with the doctor. I'll ask them how often is this needed and why is this necessary in the first place.

Ask them send you a copy of the specific Medicare code or codes supporting their demand and then share this with us please.

Calling Medicare a few weeks ago did not help me. Medicare told me to ask my DME or to consider a 3 way call where they would ask my DME and this tells me the Medicare call center is not all that well informed and are shuffling through the Medicare codes to get answers to questions just like we are.

I spent quite a bit of time researching DME rules tonight on the internet. Totally clogs my brain to read this stuff. The changes appear to be an offshoot of the Affordable Care Act.

There is some variation to the Medicare rules related to "Local Coverage Determinations (LCDs) and/or MAC Jurisdictions" which might explain why this is effecting some of us but not all of us. Understanding LCDs and Jurisdictions is way beyond what I know but I guess you can investigate further by looking for the rules that pertain to your geographic area.

Not sure how all this relates to the large online Medicare Distributors other than it would be a bit easier for them to work with the new changes given their specialized computer software and not having to shuffle through piles of paperwork. So support your local DME if you like them! or large corporations are likely to wipe them out.

The DME's appear to be responding to Medicare changes. Some DME's may be more following the rules more strictly than others, time will tell, I guess.

Unfortunately, I feel, doctors tend to be dictated by Medicare and other insurance companies in a lot of ways, sometimes not to the patient's benefit.

My recent experience:

I have been on Medicare for about three years. I live in a competitive bid region. My DME requires a new Rx each year from my sleep doc. I saw my doc in September, told him I want a new machine (mine was bought OOP before joining Medicare) He told me I had 6 months to initiate the process, without another OV. Five weeks after getting my new machine, I had a face-face with my doc. Unless I have problems, I was to see him in one year.

Consistency from Medicare? Or DME's, or insurance!
Let me know how that works out.