Ever since CMS began its overhaul of the rehab coverage and
pricing model, power mobility providers have found themselves
confused and frustrated.
HME companies are unsure how to move forward, and many have more
questions than answers. How do they respond to the new fee
schedules and the required documentation? Which wheelchairs can
they provide to their Medicare patient base and which are not
allowed?
One particular area of power mobility device reimbursement that
is causing suppliers to scratch their heads is the new medical
documentation requirement. Providers are faced not only with the
challenge of getting the required documentation from physicians in
a timely manner in order to process the claim appropriately but
also tracking it effectively.
Here are some tips that should help in gaining control of your
PMD documentation process.
IT TAKES TRAINING
The first key element in getting control of the documentation
process for power mobility is proper training. Companies must have
at least one well-trained documentation employee on staff
who has a firm grasp of what is required by Medicare.
This person must understand all of the requirements that the
patient must meet in order for the PMD to be covered: the
face-to-face requirement, the detailed written order, detailed
product description, what is in the patient chart notes and how
they all relate to complete the information circle.
Comparing the patient chart notes to the face-to-face and
detailed written order is time-consuming and requires your
documentation staff to be well-versed in the coverage
requirements.
Training your staff is more than just reviewing the policy
itself. The staff cannot simply read the requirements; they must
have a complete understanding of their meaning and what it takes to
comply. Without this knowledge, you will never be really sure
whether your claims will stand up to the scrutiny of a post-pay
audit.
If you don't want to do the training yourself, there are many
industry conferences and presentations to which you can send your
staff for training on this topic, and it is worth the time and
money to do so. Or, check with your vendors. Many manufacturers
also will be willing to help.
Also, set time aside to walk through the policy with your
billing team to make sure your staff is interpreting it correctly.
If confusion arises, discuss the concerns of team members and come
to a company-wide agreement on how to interpret the policy.
Set up processes that your staff can follow, and relay your
expectations for accomplishing their responsibilities in that
process. Once training is complete, you must put your processes in
action and audit your team.
GETTING THE PROCESS STARTED
Identify the documents that your company needs in order to
process the PMD claim and complete the product delivery.
Once that list has been determined, set a sequence of when those
documents must be received before team members can move to the next
step. This entails developing a tracking mechanism to follow the
paperwork and to assist in ensuring that it is received in a timely
manner. You can develop the sequence through your billing software
(if applicable) or a spreadsheet, whichever works best for your
company.
Areas that can be tracked might include the following:
Date provider performed the evaluation to determine the
patient's PMD needs.
Date paperwork was received from the patient evaluation from the
RESNA-certified Assistive Technology Practitioner (ATP) or
RESNA-certified Assistive Technology Supplier (ATS).
Date patient has set for the face-to-face appointment (if
known).
Callback date to confirm patient went to the face-to-face
appointment.
Callback date to follow up on anticipated receipt of
face-to-face documents and chart notes from physician.
Once the face-to-face document has been received, the date
detailed written order and product description were sent.
Callback date to follow-up on detailed written order and product
description.
If sending to Advanced Determination for Medical Coverage, the
date ADMC request was sent.
Callback date to follow up on ADMC return.
These listings are only suggestions of dates and paperwork that
could be tracked. Your company may track more steps. Decide on the
items that are the most important and pertinent to your document
retrieval process and company needs.
NOW WHAT?
Confirm that your team is working through the documents in a
methodical manner. Don't just think that your patients meet the
criteria — know they do.
Compare what Medicare requires on the face-to-face information
with what you received. Look through the document point by point.
If the face-to-face documentation meets the guidelines, review it
with the patient chart notes to ensure that the patient has the
required information in his/her medical record.
If the information on the face-to-face is incomplete and the
patient doesn't meet the requirements, communicate with the
patient, physician and/or the physical therapist/occupational
therapist (if applicable) that, based on the information provided,
the patient does not meet the criteria for Medicare coverage. See
whether there is additional information available in the patient's
medical record that was missed.
Utilizing Medicare's advanced determination option is helpful in
determining whether the prescribed PMD is medically necessary.
However, an affirmative determination relates only to whether the
item is reasonable and necessary based on the information
submitted.
An affirmative determination does not provide assurance that the
beneficiary meets Medicare eligibility requirements, nor does it
provide assurance that any other Medicare requirements (e.g., place
of service, Medicare secondary payer) have been met. Only upon
submission of a complete claim can the DME Medicare Administrative
Contractor make a full and complete determination.
While taking the necessary steps to submit an ADMC does add more
time to the entire PMD claim process, it is worth it to gain peace
of mind prior to ordering/delivering the equipment and submitting
the claim.
The request for advanced determination is sent to your region's
DME Payment Safeguard Contractor and can be faxed or mailed. The
PSC will make a determination within 30 calendar days.
Providers must send the following information for PMDs:
The order that your company received within 45 days following
the completion of the face-to-face examination. This order must
contain the following elements:
Beneficiary name
Description of the item. This may be general, such as
“power wheelchair” or “power mobility
device,” or the description may be more specific.
Date of the face-to-face examination. If the evaluation involved
multiple visits, enter the date of the last visit.
Pertinent diagnoses/conditions that relate to the need for the
power wheelchair.
Length of need
Physician's signature
Date of physician signature
There must be a date stamp or equivalent on the order to
indicate when you received it.
A detailed product description signed and dated by the
physician that lists the specific wheelchair base and all
options and accessories that will be separately billed. For each
item there must be a HCPCS code and either a narrative description
of the item or the manufacturer name/model.
The detailed product description must also list the provider's
charge and the Medicare fee schedule allowance for each item. (If
there is no fee schedule allowance, you must enter “not
applicable.”) If the manufacturer name/model for the
wheelchair base is not included on the detailed product
description, as the supplier you must provide this information.
Reports of the face-to-face examination and specialty
evaluation by the physician and other licensed/certified
medical professionals, such as a physical therapist or occupational
therapist. There must be a date stamp or equivalent on the reports
to indicate when they were received by your company.
Reports of LCMPs must include an attestation statement
indicating that the LCMP has no financial relationship with your
company. (Refer to the “Documentation Requirements”
section of the Power Mobility Devices Local Coverage Determination
for guidance about the type of information to be included in the
face-to-face exam and specialty evaluation.)
A report of the on-site home assessment, which
establishes that the beneficiary is able to use the wheelchair
ordered to assist with activities of daily living in the home.
USING YOUR SALES TEAM
In the “old days,” we thought that getting
physicians to complete a Certificate of Medical Necessity was
difficult. Now we are finding that getting physicians to understand
their role in ensuring that their patients receive the equipment
they require is even more challenging.
Since you cannot use a form to assist the physician in
completing the face-to-face evaluation, there is room for error and
incomplete information. So you need to help in educating the
physicians who refer to you about the information they must supply
according to the new PMD policy.
Sending your sales team to PMD referral sources to educate them
on the new requirements could help increase your medical
documentation success rate. Consider hosting a mini-seminar and
lunch for physicians and/or their staff members to offer training
on the subject.
To assist with the face-to-face evaluation, develop a packet
that the patient can take to the appointment detailing Medicare's
requirements regarding the exam. You can develop a similar packet
for your sales team to take when meeting with physicians and/or
staff.
Regions A and B PSC Medical Director Paul J. Hughes, MD, has
written a letter to physicians regarding Medicare prescribing
requirements for power wheelchairs and power operated vehicles. The
letter was posted on Aug. 3, 2006 — and there are a few areas
of the LCD that have been updated since — but it offers a
clear picture of what is expected from physicians by the Medicare
program. The letter is posted on the TriCenturion Web site at
target="_blank">www.tricenturion.com/content/bulletin_dyn.cfm
and may be helpful when speaking with your referral sources.
Of course there is no surefire way to get the cooperation you
need from the medical community, but just take it one step at a
time, and be persistent.
As you make decisions in the new world of power mobility,
analyze your internal processes and refine them to meet what is now
required. It is not a news flash that you will probably have to
modify the way you do business, but you also must remember to
modify the way you track the necessary medical documentation.
Moving forward in an organized and systematic fashion will
assist with efficiencies and help to improve your success rate.
Implementing processes that are understood company-wide will also
assist with decisions regarding claims payment.
Sarah Hanna is a reimbursement consultant and vice
president of ECS Billing & Consulting, Tiffin, Ohio. She has
conducted numerous training seminars and client consultations on
proper billing protocols, Medicare coverage guidelines and billing
office procedures for accounts receivable collections. Hanna can be
contacted at 419/448-5332 or
target="_blank">sarahhanna@bright.net.
