Mobility Stakeholders Cautious about PMD Face-to-Face Checklist

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.