ATLANTA — CMS came out with a face-to-face examination checklist for power mobility devices last week, but it might be a case of too little, too late, some HME providers believe.
The one-page checklist for the exam, required before physicians prescribe a PMD, is included in a Special Edition MLN Matters article (SE1112). Power mobility providers must have proof of such an exam in their records in order to be reimbursed.
CMS also issued a disclaimer with the checklist saying that it was a guide only and "does not replace the underlying medical records" or ensure Medicare payment for a PMD.
"Considering that we have been dealing with the nightmare that is the face-to-face examination for several years, I'd say it was a little late," commented Michele Gunn, CRTS, of Browning's Health Care in Orlando, Fla.
The face-to-face requirement has been a bone of contention for mobility providers, largely because guidance from CMS regarding the requirement has been murky at best.
"The industry has been asking CMS to clarify the criteria since the original NCD and LCDs were published," said Wayne Grau, vice president, contracting and business services, for The MED Group, Lubbock, Texas, referring to the coverage determinations that were issued in 2005. "The industry recognized even back then that the present guidelines are too ambiguous …
"The coverage criteria is open for interpretation, and because CMS has not clarified it, there is a lot of confusion among providers as to what meets qualifications and what does not."
That has been borne out by sky-high high denial rates for PMDs. A Jurisdiction B medical review of K0823 claims in the first quarter this year turned up a 70 percent claim error rate. A recent Jurisdiction D prepay review of K0823 claims resulted in a 90 percent error rate, mostly because of lack of documentation, according to the DME MAC.
Noridian said that of 648 claims it reviewed, 576 were denied. Some claims did not include face-to-face exams or were missing elements of the exam, the Jurisdiction D DME MAC said.
That doesn't surprise Grau.
"When any product has a very high denial rate and there are no clear-cut guidelines, then CMS must take a look and clarify those guidelines to make sure beneficiaries are going to get the equipment they qualify for," he said.
In an effort to get the documentation they need regarding the face-to-face exam, "many suppliers have created forms which have not been approved by CMS which they send to physicians and ask them to complete," Noridian said. "Even if the physician completes this type of form and puts it in his/her chart, this supplier-generated form is not a substitute for the comprehensive medical record."
Gunn said Browning's, which has been just as confused by the guidance as other providers, has nevertheless shied away from such forms. "Browning's is one of the companies that hears, 'No one else makes me do that. I usually just fill out a form,'" she said. "We have a system to collect documentation that we do not stray from.
"We also use the ADMC process for any of our chairs that qualify," she added, referring to the Advance Determination of Medicare Coverage, a program that allows suppliers and beneficiaries to request prior approval of eligible items before delivery. "It is not a guarantee, but it does seem to help if you end up at an [administrative law judge] hearing. Our claims get paid because we take the time on the front end to get the correct documentation," Gunn said.
Mobility provider Doug Westerdahl agreed. "The PMD documentation requirements have always been hard to understand, and any communication from the DME MACs that will provide additional guidance and clarification will be helpful," said Westerdahl, president of Monroe Wheelchairs in Rochester, N.Y. "However," he added, "the best checklist in the world can never replace a strong documentation review process by the supplier."
Westerdahl said the basic elements of the PMD coverage guidelines are understandable, but providers need to have knowledgeable staff reviewing the documentation at every step, ensuring that it shows the beneficiary meets the coverage guidelines, that physician chart notes are in hand and that they include the information critical for a paid claim.
"I have believed for some time that physicians are the people who understand the PMD documentation requirements the least, and the DME MACs should always be looking for ways to further educate doctors," he said.
While it appears the checklist is an attempt to do that and address the steep denial rates, Gunn is not sure whether it will be helpful or not.
"It looks like the usual stuff we see from Medicare," she said. "No one besides those of us who do this for a living will ever actually take the time to read it. The legitimate suppliers will have to break it down into the Reader's Digest condensed version for our referrals, and unscrupulous suppliers will continue to complete the paperwork as they always have."
Download a PDF of the checklist in Special Edition MLN Matters article SE1112.
