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:
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What is this patient's mobility limitation and how does it interfere with the performance of activities of daily living?
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Why can't a cane or walker meet this patient's mobility needs in the home?
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Why can't a manual wheelchair meet this patient's mobility needs in the home?
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If a PWC is provided, why can't a POV (scooter) meet this patient's mobility needs in the home?
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Does this patient have the physical and mental abilities to operate a PWC/POV safely in the home?
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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:
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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.
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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.
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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.
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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.
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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).
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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.
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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.
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Beneficiary Authorization. Make sure the patient's signature is on file authorizing the submission of a Medicare claim for payment.
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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.
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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.
