If the DMERCs were to audit your K0011s (motorized wheelchair with programmable controls) and/or your E1230s (power operated vehicles/scooters), would you survive the audit?
As part of the government's 10-point plan to curb fraud and abuse in this market, the local medical review policy (LMRP) was reviewed carefully, giving consistency on how the DMERCs will audit and reimburse for these items. Not only will there be pre-payment reviews, there will be numerous post-payment reviews to verify that the provider should have been paid based on the documentation obtained.
For K0011s and E1230s, Medicare will apply the national policy on old as well as current dates of service. The policy states that a “patient must be bed- or chair-confined without the use of a wheelchair, and this equipment is for use inside of the home.” A power chair or power-operated vehicle (POV) is covered if the patient is also “unable to operate the wheelchair manually.”
For the Record
What should you look for in a patient file? First, verify that your patients truly qualify for the equipment you are providing them, based on Medicare guidelines. If you are providing a scooter, does the patient have the upper trunk stability to operate it safely? Did one of the specialists on the certificate of medical necessity order the scooter? Just because the doctor signed a CMN does not mean the patient meets medical guidelines. And, just because Medicare paid you does not mean you will keep your money!
The CMN alone will not give you the necessary documentation to prove the patient meets the criteria set forth by policy. Essentially, CMNs serve as a screening tool, allowing the DMERCs to review the basic coverage criteria electronically.
What else do you need in the patient's medical records? The supplier will be required to obtain:
(a) a copy of the patient's medical records from the treating physician,
(b) a copy of the delivery slip,
(c) any evaluations obtained prior to the delivery of the motorized vehicle,
(d) the distance a patient can walk either with the assistance of an ambulatory aid or independently,
(e) the strength and function of the upper and lower extremities, and
(f) all of the diagnoses that apply to the patient's limited means of ambulation (neurological, muscular or cardiopulmonary disease or condition — diagnoses on question No. 6 of the CMN).
The question is, “Can this patient ambulate with or without assistance?” If you answer “yes” to this question, the patient does not qualify based on Medicare criteria. If a patient can bear weight to transfer from the bed to a chair or wheelchair, then the patient will be considered non-ambulatory.
Currently a provider may reimburse a physical or occupational therapist to evaluate a patient, but how much weight does this really have with the DMERCs? Not considered part of the patient's medical record, these evaluations will only be considered if corroborated by the medical record.
The patient's medical record can consist of a physical or occupational therapist evaluation if:
(a) performed on referral from the treating physician,
(b) performed in person and not over the telephone,
(c) performed by a Medicare provider or employee of a Medicare provider, and
(d) performed by clinicians not employed or otherwise paid by the wheelchair supplier.
Unpleasant Business
Should a provider just stop carrying powered mobility aids for beneficiaries? No, as long as you follow Medicare, Medicaid and third-party payer services' guidelines and coverage criteria.
When audited, not only do you pay back what you were paid, but you also may be subject to the RATS-STATS analysis, which gives results based on rough payment estimates.
I am currently working several post-payment audits, and I will share with you that they are most unpleasant. Unfortunately, many physicians do not have what providers need in their notes. So, guess what? The claim is denied, and you must pay back the DMERC for a claim you thought was legitimate for equipment you thought medically necessary at the time of delivery.
Educate the referring (treating) physicians on DMERC policy and on what documentation you must obtain from them in order to receive reimbursement from Medicare processors. You are allowed to communicate with the physicians and educate them — just do not “coach” them.
Prepare to Do It Right
Times are changing, and we must change with them.
Look at your internal processes to ensure that you are ready for the changes. Educate your staff appropriately, and make sure your intake coordinators understand exactly what documentation is required at intake for a patient to qualify for motorized vehicles.
If a patient walks into your store or office with a prescription for a motorized wheelchair or scooter, are you going to provide them with the item automatically because the doctor ordered it? Think about that and ask your staff that question.
However, if you obtain and evaluate all the documentation that is necessary, you will know whether your patient truly qualifies for the equipment ordered.
Visit the DMERC Web sites regularly to keep current with all of the changes. Make copies of the information and distribute it to your staff in a timely manner.
Do it right in the beginning, and you will keep your money at the end.
Jane Bunch is CEO of Kennesaw, Ga.-based JB&CS. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans, and serves as a consultant for fraud and abuse cases. She can be reached at 678/445-1221 or via e-mail at BILLHME@aol.com.
