The power mobility device industry certainly has had its share
of changes and challenges over the last few years, with the
elimination of the certificate of medical necessity and the advent
of new codes, new coverage policy and new fee schedules.
These changes have made all involved parties adjust the way that
they operate their businesses, from the PMD provider supplying the
product to the ordering physician documenting the need.
While these changes have forced everyone to adapt, they have not
diminished the fact that demand for PMDs will continue to grow as
the baby boomer generation reaches Medicare age. Those providers
that adapt the best will be well-positioned for the increased
demand in the not-so-distant future.
The final rule relating to documentation for power wheelchairs
and power-operated vehicles (POVs, or scooters) was published in
the Federal Register back on April 5, 2006, and has been
effective for claims with dates of service since June 5 of that
year.
The final rule requires that the physician's order for a power
mobility device and a copy of the report of the face-to-face
evaluation of a patient's mobility be received by the supplier
within 45 days of the completion of the face-to-face evaluation.
The report of the face-to-face examination must provide information
relating to the following questions in the chart/progress
notes:
What is this patient's mobility limitation and how does it
interfere with the performance of activities of daily living?
Why can't a cane or walker meet this patient's mobility needs in
the home?
Why can't a manual wheelchair meet this patient's mobility needs
in the home?
If a PWC is provided, why can't a POV (scooter) meet this
patient's mobility needs in the home?
Does this patient have the physical and mental abilities to
operate a PWC/POV safely in the home?
Is the patient willing and motivated to use the PWC or POV?
As you know, the specific elements that are addressed will
depend on the patient diagnosis and its progression, which are
responsible for the mobility deficit. For example, for patients
with COPD, heart failure or arthritis, the major emphasis will be
on symptoms and history of the progression of their condition
rather than on the physical exam.
Functional assessment is important for all patients. Physicians
should also provide reports of pertinent laboratory tests, x-rays
and/or other diagnostic tests (e.g., pulmonary function tests,
cardiac stress test, electromyogram, etc.) performed in the course
of management of the patient in order to help paint a clear picture
of the patient's condition in the event of medical review.
Physicians are required to document the evaluation in a detailed
narrative note in their charts in the format that they use for
other entries. According to Medicare, the narrative note must also
clearly indicate that a major reason for the visit was a mobility
evaluation.
I know many of you may be shaking your head, saying, “That
is not the manner in which physicians chart for any other health
care procedures or prescriptions.” So why should they be
expected to follow this long process for prescribing a power
mobility device? Well, because that is the standard established by
Medicare that must be met from a coverage perspective in order to
be assured payment.
Industry efforts are continuing on many different fronts to
provide additional clarity in the requirements and education, but
for now we have to work within this standard. The quality of
documentation that you receive from your referral sources therefore
becomes almost a direct result of the time you put into educating
your referral sources. The better educated your referral sources
are on the process, the better the quality of documentation you
will generally receive.
One recommendation to follow if you are experiencing significant
challenges with physicians in providing the level of information
you need is to encourage them to do a referral to a
licensed/certified medical practitioner (LCMP). According to
Medicare coverage guidelines, the physician may refer the patient
to an LCMP who has experience and training in mobility evaluations
to perform part of the face-to-face examination.
It is important to note that this person may not be an employee
of the supplier or have any financial relationship with the
supplier. (There is an exception for a supplier that is owned by a
hospital. In that situation, the LCMP working in the inpatient or
outpatient hospital setting may perform part of the face-to-face
examination.)
In order for the report of an LCMP evaluation to be considered
part of the face-to-face examination, there must be a signed and
dated attestation by the supplier that the LCMP has no financial
relationship with the supplier.
It is also important to emphasize that even if an LCMP performs
a major part of the mobility evaluation, there still must be a
face-to-face examination by the physician. This face-to-face exam
by the physician can be rudimentary in nature; however, it must be
clear that a major reason for the visit was to discuss a PMD.
Why the review course on PMD documentation requirements?
Last summer, TriCenturion, the Jurisdiction A/B DME Program
Safeguard Contractor, completed a widespread pre-payment probe
review of power wheelchairs for HCPCS K0823 (Group 2 standard
weight PWC with captain seat). The Charge Denial Rate was an
alarming 87.51 percent in Jurisdiction A and 93.36 percent for
Jurisdiction B. As you may recall, the review was conducted only in
Jurisdictions A and B.
Clearly, when denial rates are this high, the process followed
to communicate the roll-out of the changes must be evaluated and
improved.
The educational information published on the new requirements
and the overall documentation standard must be reviewed to
determine what the real problem is, and how the requirements can be
further clarified, to result in a common understanding and
expectation as to what is required in order to provide a Medicare
beneficiary with a power wheelchair.
While the industry is continuing to work on this issue with the
DME MAC medical directors, physicians, clinicians, referral sources
and suppliers, these efforts have yet to produce the increased
education or common standard that is needed from CMS.
Pride Mobility has conducted a series of seminars across the
country related to documentation with regard to the probe, as well
as a review of actual charts that providers have brought in to
learn to self-audit. Based on these events, it is clear from the
documentation we have reviewed that physicians' understanding of
the documentation process and requirements varies greatly, even
within a particular region.
So what can you do to gather complete documentation and ensure
payment moving forward under the current requirements? Here is a
list of 10 items providers should look for in a patient's file
prior to providing a PMD:
Face-to-Face Examination. The written record of the
face-to-face examination, including details of a physical
examination and narrative answers to questions about the
beneficiary's functional limitations.
PT/OT Evaluation. In the event that the treating
practitioner refers the patient to a physical/occupational
therapist (PT/OT) for an additional evaluation, the supplier must
obtain a copy of the PT/OT evaluation that has also been signed and
dated by the ordering physician.
Nine-Step Algorithm. For additional documentation
purposes, physicians should provide answers addressing the
nine-step algorithm, ruling out lesser equipment to get to the next
level of equipment needed in the algorithm.
Written prescription. The seven-element written
prescription for a PMD must be signed and dated only after the
face-to-face evaluation is complete. If a PT/OT will be performing
part of the face-to-face assessment, the prescription should be
written after all medical documentation has been reviewed by the
ordering physician.
Detailed Product Prescription. A detailed product
description (DPD) should then be developed by the provider listing
the base and all accessories that will comprise the final product.
This will also need to be signed by the ordering physician.
Keep in mind this must be a separate document from the initial
order. The DPD can be dated the same day as the initial order;
however, Medicare does not consider this to be a common occurrence
(i.e., they generally expect the order to come from the physician,
and the chair to then be configured by the provider, which usually
spans a few days).
Date Stamps. Make sure all documentation is date-stamped.
A provider has 45 days to obtain the required medical records after
the face-to-face exam and 120 days to deliver the product.
Provider Attestation. If a PT/OT is used as part of the
face-to-face evaluation, the provider must have a document in the
patient's file stating that they (the supplier) have no financial
relationship with the PT/OT performing the portion of the
face-to-face evaluation.
Beneficiary Authorization. Make sure the patient's
signature is on file authorizing the submission of a Medicare claim
for payment.
Home Assessment. At some point (even upon delivery), the
provider must assess the patient's home setting to determine if the
item the patient will be receiving is appropriate for use in the
home.
Signed Delivery Ticket. Make sure your client understands
the product, is able to operate the equipment and signs a delivery
ticket. You must also make sure the client has received the
supplier standards to review. A good idea would be to add this to
any delivery document you may have signed, as there will then be a
signed copy of the standards as proof that the patient was provided
a copy of them.
And, remember that as of April 1, an Assistive Technology
Supplier (ATS) is now required to be involved in the provision of
complex rehab equipment.
While there is a laundry list of challenges ahead, opportunities
also exist. We must recognize, for instance, the increased
importance of the provider-physician relationship that has evolved
in this marketplace.
It is now far more essential than ever to develop professional
relationships with physicians and physicians' staffs and create an
educational “information exchange” environment.
Relationships need to be created that do, in fact, include
providers and physicians as part of the same clinical team.
How do you do that? There is help. Our company, for instance,
has worked with providers to develop guides on physician resources,
choosing the right mobility solution, home assessments and other
examination and documentation reference materials in print and
Web-based formats.
These materials simplify and clearly outline the examination,
documentation and PMD ordering process and policies, and they help
clarify the responsibilities and procedures each member of the
clinical team needs to follow.
Additionally, we are joining providers in presenting seminars
and forums (that offer continuing education units) for physicians
and their staffs, as well as therapists.
These things are being done to embrace the need for strong
business alliances and to clarify the responsibilities of each
member of the clinical team. This will permit physicians to
knowingly, simply and efficiently manage their responsibilities,
which largely include the examination and the compiling of complete
patient information documents.
This clinical model may increase provider costs and could be
more difficult to manage on the front end of the ordering and
documentation process for PMDs. However, these requirements should
protect providers on the back end (e.g., in claims review and/or
hearings) by yielding more complete documentation.
The industry has a real opportunity to work with CMS on
improving upon the status quo. If, as an industry, we are willing
to work to strengthen relationships with referral sources, get
involved with state and national organizations and show our elected
officials that DME providers are part of the solution, the future
shows promise. But like any other initiative, it will take hard
work and a commitment to get there.
Seth Johnson is vice president of government affairs for
Pride Mobility Products Corp., Exeter, Pa., and is a member of the
American Association for Homecare's Rehab and Assistive Technology
Council. He can be contacted at sjohnson@pridemobility.com or by phone at
800/800-8586.
