CMS-R-263.Site Visit Form Revisions - Crosswalk from old to new

Revisions to Form CMS-R-263 – Site Investigation for – Durable Medical Equipment (DME) Suppliers

Change #	Page #	Section	Question Number	Action to be performed	Changes to the Application	Reason for the Change
	All	All	All	Enlarged font	12 point font	Revised for section 508 compliance
	1	Reason For Visit	n/a	separate “re-enrollment” from “application”	○ Reactivation/Re-enrollment	Revised to clarify the reason for visit.
	1	Reason For Visit	n/a	Delete “EIN”	Replace “EIN” with “NPI”	This addition is in compliance with the NPI Final Rule and is revised to reflect supplier identifier currently collected.
	1	Reason For Visit	n/a	Add “(NSC/PTAN) under “Supplier Number”	(NSC/PTAN) – font size 6	Clarification for the site inspector of the type of number being collected (DMEPOS supplier specific).
	1	Header Box	n/a	Add	“PRESENT (“ - bolded	Editorial change - Bolded for consistency with header.
	1	Interview of Individuals Present	1	Replace: Authorized Representative with:	Individual Interviewed	Changed description to plain language
	1	Interview of Individuals Present	2	Add	or has previously	Revised to clarify instruction to the site inspector.
	1	Interview of Individuals Present	2	Add	additional locations/	Revised to clarify instruction to the site inspector.
	2	Facility Information	5	Add the word Only to Warehouse	○ Warehouse Only	Revised to clarify checkbox choice for the site inspector.
	2	Facility Information	5	Add the following check boxes under Type of Facility	○ Warehouse with Office ○ P.O./Commercial Mailbox	Revised for clarification purposes and to ensure information is properly furnished.
	2	Facility Information	5b	Add signs of and activity around customer	…signs of customer activity…	Clarified question to more accurately request desired information.

Change #	Page #	Section	Question Number	Action to be performed	Changes to the Application	Reason for the Change
	2	Facility Information	5d	Delete question about local zoning requirements		This information is no longer necessary.
	2	Facility Information	8	Add Sunday to list of hours of operation	Sunday - bolded	Revised to ensure information is properly furnished and formatted.
	2	Facility Information	8	Add Total Hours and end of list of hours of operation	Total Hours	Added to collect total hours of operation for compliance with supplier quality standards
	2	Facility Information	9	Delete and between companies and owners – replace with comma	companies, owners	Grammar change caused by rewording question.
	2	Facility Information	9	Add and type of business and example in question	…companies, owners and type of business (e.g., physician office)	Revised to ensure correct information is properly furnished.
	3	Records & Telephone	10	Delete business – replace with patient	Are the patient records maintained at this location?	Clarified question to more accurately request desired information.
	3	Records & Telephone	10c	Add a line	_______________________________	More space was needed to explain supplier’s answer
	3	Records & Telephone	11	Delete viewed phone bill as an option		Viewing the telephone bill is no longer a reliable verification
	3	Records & Telephone	11	Add internet search as an option	○ Internet Search	Updated to keep up with technology and to provide another form of reliable verification
	3	Records & Telephone	11	Delete questions and check boxes about phone call origination		This information is no longer necessary.
	3	Records & Telephone	11	Add question	What is the business telephone number: _________	Revised to ensure information is properly furnished.
	3	Licensing/ Certification	13	Add additional detail to question	Are the supplier’s business, customers, and employees covered by comprehensive liability insurance with the NSC listed as a Certificate Holder?	Added detail to verify compliance with supplier standards found in 42 CFR § 424.57.

Change #	Page #	Section	Question Number	Action to be performed	Changes to the Application	Reason for the Change
	3	Licensing/ Certification	14	Require proof of employment, licensing and certification for custom fitted or fabricated Orthotic and Prosthetic sale items	If yes, provide proof of employment and copies of licenses/certifications for the individual(s) providing this service.	Revised to ensure information is properly furnished.
	3	Licensing/ Certification	14	Add check box	○ Copy Attached	Revised to ensure information is properly furnished.
	3	Licensing/ Certification	14b	Format line	Telephone # ( )________________	Editorial change.
	4	Licensing/ Certification	15	Require proof of employment, licensing and certification for diabetic footwear	If yes, provide proof of employment and copies of licenses/certifications for the individual(s) providing this service.	Revised to ensure information is properly furnished.
	4	Licensing/ Certification	15	Add check box	○ Copy Attached	Revised to ensure information is properly furnished.
	4	Licensing/ Certification	16	Require proof of employment, licensing and certification for oxygen or oxygen related equipment	If yes, provide proof of employment and copies of licenses/certifications for the individual(s) providing this service.	Revised to ensure information is properly furnished.
	4	Licensing/ Certification	16	Add check box	○ Copy Attached	Revised to ensure information is properly furnished.
	4	Inventory	17a	Delete Is any of the inventory present intended for rental/sale to		Deleted to reword question for accuracy.
	4	Inventory	17a	Reword question	Does the supplier provide products/services to other than Medicare beneficiaries?	Clarified question to more accurately request desired information.
	4	Inventory	17a	Add colon after Describe	:	Editorial change.
	4	Inventory	17a	Format line	____________________________	Editorial change.
	4	Inventory	17b	Delete qualifier – If “Yes”,		Deleted to reword question for accuracy.

Change #	Page #	Section	Question Number	Action to be performed	Changes to the Application	Reason for the Change
	4	Inventory	17b	Reword question	Is all of the inventory stored on site?	Clarified question to more accurately request desired information.
	4	Inventory	Between 17b and 17c	Format space	Format line to 4 point font	Editorial change.
	4	Inventory	17c	Delete any		Deleted to reword question for accuracy.
	4	Inventory	17c	Reword question	If the supplier does not have a sufficient amount of inventory in stock, do they have a contract with another company to purchase DME supplies?	Clarified question to more accurately request desired information.
	4	Inventory	17c	Add check box	○ N/A	Added for more accurate reporting.
	4	Inventory	17c	Add check box	○ Copy Attached	Revised to ensure information is properly furnished.
	4	Contact With Beneficiary	18	Add current	Is a current copy of the Supplier Standards provided to all Medicare patients?	Clarified question to more accurately request desired information.
	5	Contact With Beneficiary	20	Add check box	○ Copy Attached	Revised to ensure information is properly furnished.
	5	Contact With Beneficiary	21	Replace resolution with log and reword question	Does the supplier have a written complaint procedure and log established?	Revised to clarify instruction to the site inspector.
	5	Contact With Beneficiary	25	Delete purchase option and replace with Capped Rental Policy	… and of the Capped Rental Policy?	Clarified question to more accurately request desired information.
	5	Contact With Beneficiary	27	Add and care for	…how to use and care for Medicare covered items…	Clarified question to more accurately request desired information.
	5	Contact With Beneficiary	27	Add of brochures	(This information may consist of brochures from the supplier…	Correction of error – the former copy did not include of what the information may consist

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