In mid-July, the DMERCs posted an article designed to provide more information regarding the documentation that suppliers must obtain from prescribing physicians in conjunction with orders for power mobility devices.
This information was issued after almost a year of demands from the industry and physicians that CMS provide much more clarity regarding the types and scope of documentation necessary to substantiate medical need under the new National Coverage Determination and the new face-to-face examination regulation.
The DMERC policy does provide more information regarding documentation, but it also places significant new burdens on the prescribing physician and suppliers. And the unanswered question remains whether prescribing physicians will actually provide the scope and depth of information that the DMERCs expect. The information the DMERCs are asking physicians to document in the beneficiary's medical record is far beyond the scope and depth of information they typically provide and will require suppliers to provide extensive physician education.
Of enormous concern is the language that states that Medicare's coverage of a wheelchair is determined solely by the patient's mobility needs within the home and, therefore, that the examination must clearly distinguish the patient's abilities and needs within the home from any additional needs for use outside the home. Does this mean that beneficiaries will essentially be confined to their homes because Medicare will only cover PMDs that are appropriate in the home and not practically usable in the long term outside the home?
Following are key components of the guidance:
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Orders: The physician order and report of the face-to-face exam must be received by the supplier within 45 days of the exam and prior to delivery of the device (unless the exam is performed during a hospital or nursing home stay). To document receipt, suppliers must use a date stamp or equivalent on the order and the exam report when they are received.
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Delivery: For claims with dates of service on or after Aug. 24, 2006, the delivery must be within 120 days of the face-to face exam. (For power wheelchairs that receive an affirmative determination through the Advance Determination of Medicare Coverage process, delivery must occur within six months of the determination.)
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Face-to-Face Examination: New information regarding issues the physician should address in the report of the face-to-face exam include:
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 power wheelchair is ordered, why can't a power-operated vehicle (scooter) meet this patient's mobility needs in the home?
Does this patient have the physical and mental abilities to operate a PWC or POV safely in the home?
Is the patient willing and motivated to use the PWC or POV?
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Forms: If the physician completes a form that the supplier has created and puts it in his or her chart, this is not a substitute for the comprehensive medical record information.
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Detailed Product Description: The supplier must prepare a written document that lists the base HCPCS code, manufacturer name/model and options and accessories that will be separately billed. For claims with dates of service on or after Aug. 24, 2006, the supplier must list the charge and the Medicare fee schedule allowance for each separately billed item. The physician is required to sign and date this detailed product description, and it must be returned to the supplier prior to delivery.
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PT/OT Referrals: The physician may refer the patient to a licensed/certified medical professional who has experience and training in mobility evaluations to perform part of the face-to-face examination, but this person may not be an employee of the supplier or have any financial relationship with the supplier (unless the supplier is owned by a hospital).
A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her by phone at 440/329-6226 or by e-mail at cbachenheimer@invacare.com.
