Physician’s Order for TENS UnitAcct:

Date of Order:
Patient Name: / DOB:
Date of Face-to-Face (F2F) Examination: / (must be within 6 months prior to order)
Diagnosis Code(s) supporting need for TENS Unit:

A TENS Unit is covered for the treatment of acute post-operative pain or chronic, intractable pain.

ACUTE POSTOPERATIVE PAIN: Coverage limited to 30 days from surgery date

There must be documentation in the patient medical record of:

1.Date and Nature of Surgery

2. Location and severity of pain

CHRONIC, INTRACTABLE PAIN: does NOT include low back pain, headache, abdominal/pelvic pain, or TMJ pain

Chronic low back pain (CLBP) is only covered if patient is enrolled in an approved clinical study

There must be documentation in the patient medical record of:

1.Location and severity of pain

2.Duration of time the patient has had the pain

3.Presumed etiology of the pain

4.Prior treatment, i.e. medication and/or physical therapy, and results of that treatment

Medicare patients:TENS unit must be used by patient on trial basisminimum of 30 days, no longer than 60 days.

  • The trial period must be monitored by the treating physician to determine if the TENS unit is helping to control the patient’s pain.
  • Patient must be re-evaluated at end of trial period and medical record must indicate:

How often patient used the TENS unit

Typical duration of use each time

Effectiveness of therapy, i.e. documentation that the patient is likely to benefit from use of a TENS unit over a long period of time

Physician Order (Ordering Physician must be the treating physician for the condition justifying need for TENS)

Start Date (if different from Date of Order):
Length of Need:12 monthsLifetimeOther:

Equipment:

Transcutaneous Electrical Nerve Stimulation (TENS) Device, 4 leads (E0730), includes:

Electrical Stimulator Supplies (A4595)4 per month (electrodes, lead wires)

Replacement Lead Wires (A4557) 4 per year

Physician Signature: / Date:
Physician Name: (please print) / NPI:

***Must attach copy of qualifying F2F examination***

Fax back to:

TENS Unit Order and Documentation Requirements

Medicare, and other insurance providers who follow Medicare guidelines, requires that a physician, NP, CNS or PA has had a Face-to-Face (F2F) examination with the patient that documents that the patient was evaluated and/or treated for a condition that supports the need for the prescribed equipment. This can be an inpatient admit H&P, discharge note or progress note, or an outpatient chart note. The date of the F2F exam may be no older than 6 months prior to the prescription date.

A Written Order Prior to Delivery (WOPD) is also required; the WOPD cannot be completed until after the F2F exam, and must be received by the supplier prior to dispensing the equipment. This order must contain:

  • Patient’s name
  • Physician’s name
  • Date of the order and the start date, if start date is different from order date
  • Detailed description of the item(s)
/
  • Ordering Practitioner’s National Provider Identifier (NPI)
  • Signature of ordering practitioner and signature date. Signature and date stamps are not allowed. Signatures must be legible and/or physician’s name must also be printed.

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TENS Unit Coverage Criteria: A TENS Unit is covered for the treatment of patients with chronic, intractable pain or acute post-operative pain when ONE of the following coverage criteria 1-3 is met. The qualifying criteria for the prescribed equipment must be documented in the F2F notes.The physician ordering the TENS unit and related supplies must be the treating physician for the disease or condition justifying the need for the TENS unit.

  1. Acute post-operative pain: Coverage is limited to 30 days from the day of surgery. Payment will be made only as a rental. There must be information in the medical record documenting:
  • Date and Nature of the surgery
  • Location and severity of pain
  1. Chronic pain other than low back pain: must meet all criteria A-C
  1. The presumed etiology of the pain must be a type that typically responds to TENS therapy

(this does NOT include headache, abdominal pain, pelvic pain or TMJ pain); and

  1. The pain must have been present for at least 3 months; and
  2. Other appropriate treatment modalities have been tried and failed.

There must be information in the medical record describing:

  • Location and severity of pain
  • Duration of time the patient has had the pain
  • Presumed etiology of the pain
  • Prior treatment and results of that treatment

The TENS unit must be used by the patient on a trial basis for a minimum of 30 days, but not to exceed 60 days. The trial period will be paid as a rental. The trial period must be monitored by the treating physician to determine if the TENS unit is helping to control the patient’s pain. For coverage of a purchase at the end of the trial period, the treating physician must determine that the patient is likely to benefit from use of a TENS unit over a long period of time. This information must be documented in the patient medical record.

  1. Chronic Low Back Pain (CLBP) is only covered if the patient is enrolled in an approved clinical study and has a qualifying diagnosis.

***Physicians who have patients with Medicare/Medicare replacement insurances are also required to complete a

Certificate of Medical Necessity for purchase of the equipment; this will be faxed to the doctor for completion

once all qualifying documentation has been received by the supplier.***

Thank you for making Rice Home Medical part of your healthcare team. Please call 320-235-8434 with questions.

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