External Infusion Pump Order Template Draft - CMS

DRAFTUse of this template is voluntary / optionalExternal Infusion PumpOrder Template GuidancePurposeThis template is designed to assist a clinician in completing an order for an external infusion pump,related drugs, and supplies to meet requirements for Medicare eligibility and coverage. This template,when completed appropriately, meets the requirements for a Written Order Prior to Delivery (WOPD)and a Detailed Written Order (DWO). This template is available to the clinician and can be kept on filewith the patient’s medical record or can be used to develop an order template for use with the systemcontaining the patient’s electronic medical record.A Face-to-Face (F2F) Encounter, as required by Medicare when an external ambulatory infusion pump(E0784) for the delivery of insulin subcutaneously, must be completed within a 6-month timeframe priorto completion of a WOPD. All other external infusion pumps, supplies, and Medicare covered drugs donot have a F2F Encounter requirement but are required to have a DWO prior to claim submission.Completing the External Infusion Pump Order Template does not guarantee eligibility and coverage, butit does provide guidance in support of external infusion services ordered and billed to Medicare. Whereappropriate, this template may be used with the External Infusion Pump F2F Encounter Template andExternal Insulin Infusion Pump Laboratory Test Results Template.Patient EligibilityEligibility for coverage of external infusion therapy under Medicare requires a physician/ Non-PhysicianPractitioner (NPP) 1 to establish that coverage criteria are met. This helps to ensure the external infusionpump, related drugs, and supplies to be provided are consistent with the physician’s prescription andsupported in the documentation of the patient’s medical record.The physician/NPP must document that the patient has a substantiated diagnosis supporting the needfor use of an external infusion pump to deliver an Medicare covered drug indicated for the treatment oftheir medical condition. The National Coverage Determination (NCD – 280.14) and the Local CoverageDetermination (LCD L33794) provide coverage criteria for external infusion pumps, related supplies andMedicare covered drugs.Covered diagnosis/indications may include: (See Appendix A for further details) Iron Poisoning / Chronic Iron OverloadPrimary ImmunodeficiencyHypercalcemiaA Medicare allowed NPP is defined as a nurse practitioner, clinical nurse specialist, certified midwife orphysician assistant (as those terms are defined in section 1861 (aa) (5) of the Social Security Act) who isworking in accordance with State law.1External Infusion Pump Order Template Draft R1.0a 4/30/2018Page 1

DRAFT Parkinson’s diseaseAcute lymphoblastic leukemiaChemotherapy for treatment of primary hepatocellular carcinoma or colorectal cancer wherethe disease is unresectable or where the beneficiary refuses surgical excision.Intractable Pain caused by cancerContinuous Subcutaneous Insulin Infusion (CSII) PumpsPulmonary hypertensionStage D heart failure - inotropic therapyAnti-viral (Those covered by Medicare)Anti-fungalWhat needs to be specified on the order for a WOPD?The WOPD must include at a minimum [42 CFR 410.38(g)(4)]: Beneficiary’s name;Item of DME ordered;Prescribing practitioner’s National Provider Identifier (NPI);Signature of the prescribing practitioner; andDate of the order.What needs to be specified on the order for a DWO?For a DMEPOS item that is not on the DME List of Specified Covered Items, according to 1834(a)(11)(B)(i)of the Act, that item is required to have a DWO unless Medicare policy specifies otherwise.The DWO must include at a minimum: Beneficiary’s name;Detailed description of the item(s)2 ordered;Physician/NPP name;Physician/NPP signature and signature date; andStart date of the order or the date order was writtenIf the written order is for supplies provided on a periodic basis, the written order should includeappropriate information on the following: Quantity used;Frequency of change; andDuration of need.If the supply is a drug, the order must specify the following: Name of the drug;Concentration (if applicable);Dosage;Quantity;Description can be either a narrative description or a brand name/model number and must include all options oradditional features that will be separately billed or that will require an upgraded code2External Infusion Pump Order Template Draft R1.0a 4/30/2018Page 2

DRAFT Frequency of administration;Duration of infusion (if applicable); andNumber of refills (if applicable).The order template includes information from the clinician that is required by the supplier whencompleting the DME Information Form (DIF) (CMS-10125 – External Infusion Pumps) required forreimbursement by Medicare.Who can complete the external infusion pump order template?Physician/NPP who performs a F2F Encounter (within 6 months prior to completion of a WOPD for theinfusion services) or an in-person evaluation, (prior to completing a DWO), of the patient’s medicalcondition indicating and supporting the need for use of an external infusion pump, related Medicarecovered drugs, and supplies.Note: If the order template is used:1) CDEs in black Calibri are required2) CDEs in burnt orange Italics Calibri are required if the condition is met3) CDEs in blue Times New Roman are recommended but not requiredVersion R1.0aExternal Infusion Pump Order Template Draft R1.0a 4/30/2018Page 3

DRAFTUse of this template is voluntary / optionalExternal Infusion Pump Order TemplatePatient Information:Last name:First name:MI:Address:City:State:Telephone number and extension: (DOB (MM/DD/YYYY):Height:)Zip:-Gender:xMFOther Medicare ID:Weight:Provider (physician/allowed NPP) who performed the face-to-face examination (see guidance):Check here if same as ordering provider:Last name:NPI:First name:MI:Suffix:Date of face-to-face encounter (DD/MM/YYY):Patient medical condition / diagnoses:Treatment of diabetesImmunodeficiencyPulmonary hypertensionHypercalcemiaParkinson’s diseaseAcute lymphoblastic leukemia, in relapseChronic iron overloadIntractable/chronic painChemotherapyStage D heart failure - inotropic therapyAnti-viralAnti-fungalOtherICD-10:(see Appendix C)ICD-10:(D80.0-D83.9, see Appendix D)ICD-10:ICD-10: E83.52ICD-10: G20ICD-10: der date, if different from date of signature (MM/DD/YYYY):Start date, if different from date of order (MM/DD/YYYY):Type of order:Initial or original order [select drug(s) and associated external infusion pump, if appropriate]Reorder for drugs only (external infusion pump should not be selected)Change in status:Revision of order:Patient relocatedDifferent supplierEquipment or other itemsOtherFrequency of use or amount prescribedOther:External Infusion Pump Order Template Draft R1.0a 4/30/2018Page 4

DRAFTPlace of service:Patient’s home (12)End Stage Renal Disease facility (ESRD) (65)Skilled Nursing Facility (SNF) (31)Other:Facility name (if appropriate):Address:City:State:Telephone number and extension: ()-Zip:xOrder drug(s) and external infusion pump based on medical condition / diagnosis (see Appendices A-Efor details):Treatment of diabetesDrug (unit dose)Insulin (50 units)ICD-10:(see Appendix C)HCPCS RouteConc.Volume DurationFreq.Qty/RefillsJ1817External Infusion PumpE0784 - External ambulatory infusion pump for insulin (requires WOPD and F2F evaluation)Other accessories or options:ImmunodeficiencyDrug (unit dose)ICD-10:(D80.0-D83.9, see Appendix D)HCPCS RouteConc.Hizentra (100 mg)J1559Gamunex-C (500 mg)J1561Vivaglobin (100 mg)J1562Gammagard (500 mg)J1569Hyqvia (100 mg)J1575Volume DurationFreq.Qty/RefillsFreq.Qty/RefillsExternal Infusion PumpE0779 - External ambulatory infusion pump for 8 hour or greater infusionsE0781 - Single or Multi-channel pump worn by patient for J1575 onlyOther accessories or options:Pulmonary hypertensionDrug (unit dose)ICD-10:HCPCS RouteEpoprostenol (0.5 mg)J1325Treprostinil (1 mg)J3285Conc.Volume DurationExternal Infusion PumpK0455 - Infusion pump used for uninterrupted parenteral administrationOther accessories or options:External Infusion Pump Order Template Draft R1.0a 4/30/2018Page 5

DRAFTNote: The injectable drugs below may utilize any of the following external infusion pumps. Please select externalinfusion pump here and drug(s) below:External Infusion PumpE0779 - External ambulatory infusion pump for 8 hour or greater infusionsE0780 - External ambulatory infusion pump for infusions less than 8 hoursE0781 - Single or Multi-channel pump worn by patientE0791 - Parenteral infusion pump, stationary, single or multi-channelE0776 - IV Pole (for use with E0791 only)HypercalcemiaICD-10: E83.52Drug (unit dose)Gallium Nitrate (1 mg)HCPCS RouteConc.Volume DurationFreq.Qty/RefillsConc.Volume DurationFreq.Qty/RefillsConc.Volume DurationFreq.Qty/RefillsConc.Volume DurationFreq.Qty/RefillsConc.Volume DurationFreq.Qty/RefillsJ1457Other accessories or options:Parkinson’s diseaseDrug (unit dose)ICD-10: G20HCPCS RouteCarbidopa (5 mg)/ Levodopa (20 mg) J7340Other accessories or options:Acute lymphoblastic leukemia, in relapse ICD-10: C91.02Drug (unit dose)Blinatumomab (1 ug)HCPCS RouteJ9039Other accessories or options:Chronic iron overloadDrug (unit dose)Deferoxamine Mesylate (500 mg)ICD-10:HCPCS RouteJ0895Other accessories or options:Intractable/chronic painDrug (unit dose)ICD-10:HCPCS RouteFentanyl citrate (0.1 mg)J3010Ziconotide (1 ug)J2278Hydromorphone (up to 4 mg)J1170Morphine sulfate (up to 10 mg)J2270Morphine sulfate preservative freeJ2274(10 mg)Meperidine Hydrochloride (100 mg)J2175Other accessories or options:External Infusion Pump Order Template Draft R1.0a 4/30/2018Page 6

DRAFTNote: The injectable drugs below may utilize any of the following external infusion pumps. Please select externalinfusion pump here and drug(s) below:External Infusion PumpE0779 - External ambulatory infusion pump for 8 hour or greater infusionsE0780 - External ambulatory infusion pump for infusions less than 8 hoursE0781 - Single or Multi-channel pump worn by patientE0791 - Parenteral infusion pump, stationary, single or multi-channelE0776 - IV Pole (for use with E0791 only)ChemotherapyICD-10:Drug (unit dose)HCPCS RouteCladribine (1 mg)J9065Fluorouracil (500 mg)J9190Cytarabine (100 mg)J9100Bleomycin Sulfate (15 units)J9040Fluoxuridine (500 mg)J9200Doxorubicin Hydrochloride (10 mg)J9000Vincristine Sulfate (1 mg)J9370Vinblastine Sulfate (1 mg)J9360Conc.Volume DurationFreq.Qty/RefillsConc.Volume DurationFreq.Qty/RefillsConc.Volume DurationFreq.Qty/RefillsConc.Volume DurationFreq.Qty/RefillsOther accessories or options:Stage D heart failure - inotropic therapyDrug (unit dose)ICD-10:HCPCS RouteDobutamine Hydrochloride (250 mg) J1250Dopamine HCL (40 mg)J1265Milrinone Lactate (5 mg)J2260Other accessories or options:Anti-viralICD-10:Drug (unit dose)HCPCS RouteAcyclovir (5 mg)J0133Foscarnet sodium (1000 mg)J1455Ganciclovir Sodium (500 mg)J1570Other accessories or options:Anti-fungalICD-10:Drug (unit dose)Amphotericin B (50 mg)HCPCS RouteJ0285Amphotericin B lipid complex (10 mg) J0287Amphotericin B cholesteryl sulfateJ0288Complex (10 mg)Amphotericin B Liposome (10 mg)J0289Other accessories or options:External Infusion Pump Order Template Draft R1.0a 4/30/2018Page 7

DRAFTOtherICD-10:Drug (unit dose)HCPCS RouteNOC DME injection drugsConc.Volume DurationFreq.Qty/RefillsJ7799External Infusion PumpExternal infusion pump:Other accessories or options:Signature, name, signature date, NPI, address, and telephone numberSignature:Name (Printed):Date (MM/DD/YYYY):NPI:Address:City:Telephone number and extension: (State:)-Zip:xExternal Infusion Pump Order Template Draft R1.0a 4/30/2018Page 8

Apr 30, 2018 · Order Template Guidance . Purpose . This template is designed to assist a clinician in completing an order for an external infusion pump, related drugs, and supplies to meet requirements for Medicare eligibility and coverage. This template, when completed appropriately, meets the requirements for a Written Order Prior to Delivery (WOPD)