WOPD and Face-to-Face Encounter Requirements

What You Need to Know

A Work Order Prior to Delivery is a Standard Written Order that is obtained on or before the date of delivery as opposed to the date of claim submission. All codes requiring a WOPD also require a face-to-face encounter with a physician within 6 months prior to the WOPD. For items other than Power Mobility Devices, the face-to-face encounter does not need to be completed by the prescribing physician. However, the prescribing physician must obtain documentation from a qualifying face-to-face appointment and verify that it occurred within the past 6 months. Physicians can also use telemedicine to complete a face-to-face encounter as long as a valid telehealth appointment is billed to Medicare. It is important to note that there may be some scenarios where a telehealth visit is not appropriate if the LCD/Policy Article coverage criteria cannot be met during a virtual appointment (i.e., objective measurement of knee joint laxity). The WOPD and face-to-face encounter guidelines are established in the CMS article Standard Documentation Requirements for All Claims Submitted to DME MACs (55426).

Originally, Medicare required WOPDs and face-to-face encounters for PMDs only. In 2022, they created a Required List that included 7 other DMEPOS items, including 1 osteogenesis stimulator code and 6 prefabricated orthotic codes. In 2023, they updated the list once again and added 10 more orthotic codes, including both prefabricated and custom fabricated orthoses. Currently, the following 16 orthotic codes require a WOPD and face-to-face encounter:

LSOs: L0631, L0637, L0648, and L0650

KOs: L1832, L1833, L1843, and L1851

SEWHO: L3960

AFOs: L1932, L1940, L1951, L1960, and L1970

KAFOs: L2005 and L2036

 What this Means for You

Prior to providing an orthosis to your patient, it is important to understand if any of the associated billing codes require a WOPD and face-to-face encounter. There are several different ways to find this information, including the Required List document on the CMS website and customized lookup tools on both the Noridian and CGS websites. If you determine that the orthosis you are providing does require a WOPD and face-to-face encounter, then you must obtain an SWO prior to the item's delivery and a physician visit is required within six months prior to the date on the SWO. The actual information provided in both the SWO and physician notes must follow the same guidelines as all other DMEPOS items. Currently, the five orthotic codes that require prior authorization from Medicare are also included on the Required List. Therefore, the WOPD and physician notes from the face-to-face encounter need to be submitted along with your prior authorization request to obtain approval.

More information on WOPDs and face-to-face encounters, including the most up-to-date Required List, can be found on the CMS DMEPOS Order Requirements webpage.