Among the requirements that must be satisfied when dispensing surgical dressings and compression garments is a face-to-face (FTF) examination. This FTF exam must take place within six months of the time the order is written for the surgical dressing(s) or compression garment. It is acceptable if the FTF exam takes place on the same day the order is written. In this FTF exam, the beneficiary must be evaluated and/or treated for a condition that warrants the need for the item(s) ordered.
Face-To-Face Exam Documentation Requirements
Not only must the FTF exam meet the requirements outlined above, but there are also certain points of documentation that must be included. The documentation for this visit must include:
- the beneficiary’s name
- the date of the visit
- the provider’s signature
The documentation must also reflect that the outcome of the visit supports the need for the item(s) ordered. The note for the FTF exam must be in the appropriate section of the beneficiary’s medical record.
When the Face-To-Face Exam is Required
This FTF exam must take place, be properly documented, and be medically necessary every time an order is written for surgical dressings and/or compression garments. This holds true not only for the initial prescription but also for when there is a change in the supplier when an item needs to be replaced, and when there is a change in the prescription.
DISCLAIMER: The information provided here is intended to educate health care providers regarding compliance for ICD, CPT, and HCPCS coding. The information provided does not guarantee reimbursement and is accurate to the best of our knowledge at the time of this publication. Coding guidelines can change and we encourage you to stay up to date. The existence of a code does not guarantee payment.
Dr. Jeffrey D. Lehrman, DPM, FASPS, MAPWCA, CPC, CPMA
Dr. Lehrman is a podiatrist practicing in Fort Collins, CO and operates Lehrman Consulting, LLC which provides consultation services regarding coding, compliance and documentation. Dr. Lehrman is a Certified Professional Coder and Certified Professional Medical Auditor. He serves as a staff liaison at the AMA CPT® Editorial Panel meetings where CPT codes are created, edited, and deleted. He is a Diplomate of the American Board of Foot and Ankle Surgery, Fellow of the American Society of Podiatric Surgeons, and is recognized as a “Master” by the American Professional Wound Care Association. Dr Lehrman is a Fellow of the American Academy of Podiatric Practice Management, Past Director of the American Professional Wound Care Association Board of Directors, and is a Past Chairman of the Board of the American Society of Podiatric Surgeons. Dr. Lehrman is also on the editorial advisory board of the journal WOUNDS.
