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7 Element Order: in The Same Provider's Handwriting

The document outlines the 7 required elements that must be completed by an ordering provider for Medicare documentation. The 7 elements include patient name, date of face-to-face exam, ICD-10 codes and diagnoses, length of need, equipment ordered, provider signature and date, and provider NPI number. All elements must be in the provider's handwriting.

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MIPA 2ALYA RANIAH NURSYAFA
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14 views

7 Element Order: in The Same Provider's Handwriting

The document outlines the 7 required elements that must be completed by an ordering provider for Medicare documentation. The 7 elements include patient name, date of face-to-face exam, ICD-10 codes and diagnoses, length of need, equipment ordered, provider signature and date, and provider NPI number. All elements must be in the provider's handwriting.

Uploaded by

MIPA 2ALYA RANIAH NURSYAFA
Copyright
© © All Rights Reserved
Available Formats
Download as PDF, TXT or read online on Scribd
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7 Element Order

Note: Medicare requires that ALL 7 elements MUST be completed by the ordering provider and MUST be
in the same provider’s handwriting.

1.) Patient Name: ___________________________________________________________________

2.) Date of Face to Face: _______________________________________________________________


3.) ICD-10 Code Diagnosis
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________
___________ . ________ __________________________________________________

4.) Length of Need: __________________________________________________ (99 Months = Lifetime)

5.) Equipment Ordered: _______________________________________________________________


_______________________________________________________________________________

6.) Provider’s Signature: _______________________________________________(No Signature Stamps)

Provider’s Name Printed: ____________________________________________________________

7.) Date of Provider’s Signature: _________________________________________________________


Provider NPI: ____________________________________________________________________

This order must be received within 45 days of the face-to-face exam.


Per cms.gov: The supplier may provide a template order listing the seven required elements but is prohibited from completing any part of
it. The treating practitioner completing the face-to-face requirements must write the 7-Element Order. The 7-Element Order may only be
written after the completion of the face-to-face exam requirements. Refer to the Policy Article NON-MEDICAL NECESSITY COVERAGE AND
PAYMENT RULES section for information regarding the statutory requirements for PMDs.
(Rev. 1/5/17)

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