For years, providers have called out Medicare's "inefficient guidelines for documenting the medical necessity of power wheelchairs"

WASHINGTON — As the industry wrestles with competitive bidding, the PECOS and ongoing problems with the oxygen cap, another issue that continues to plague HME providers is documenting claims for power wheelchairs.

A recent review of 1,000 K0823 power wheelchair claims in Jurisdiction A, for example, showed only 237 were allowed while 763 were denied. NHIC, the Jurisdiction A DME MAC, said a whopping 78.9 percent of the claims had documentation that was incomplete.

The American Association for Homecare pointed to the documentation challenge for PWCs once again in its latest editions of Mobility Matters, a bulletin sent to Congress, the administration, policymakers and others.

For years, providers have called out Medicare's "inefficient guidelines for documenting the medical necessity of power wheelchairs," according to the July 16 bulletin. "It is the root cause of claim denials that are frequently reversed, the target of excessive audits and it restricts access to power wheelchairs for patients."

In a rare perspective on the matter from a physician, Jerald Winakur, MD, FACP, CMD, told the bulletin's readers he is as frustrated as providers are about the situation.

Winakur, a clinical professor of medicine and associate faculty member at the Center for Medical Humanities and Ethics at the University of Texas Health Science Center in San Antonio, said CMS has taken what should be a simple task and made it needlessly difficult. "I cannot just order this device as I would a cane or a wheelchair or a walker … I am mandated to see the patient face-to-face even if he/she had just been in last week," Winakur wrote.

He added that he had now preformed several such evaluations. "They take me most of an hour to see my patient, examine him or her, complete the redundant paperwork. I am also required to write a chart note in the patient's medical record re-hashing the same information I have put on a form, rather than just putting the form in the patient record. Then there is all the work my staff has to do behind the scenes — several communications with the provider by phone.

"Even worse," he continued, "doctors and providers cannot get clear guidance as to what information is required by CMS after the mandated 'face-to- face' encounters."

Winakur doesn't mince words. "This is how I feel," he said. "CMS has developed a hodge-podge response to the needs of our citizenry … By its actions, Medicare stifles innovation, discourages physician participation in the program, and — most egregiously — restricts the autonomy of elderly and disabled citizens, the very ones it is the mission of CMS to help. And, paradoxically, CMS ends up spending more money, not less, in the long run. This is shameful behavior that deserves the transparent light of day shone brightly upon it.

"At a time when our elderly population is burgeoning, at a time when the kinds of doctors needed to care for this population is plummeting, CMS continues to undermine our citizens and those of us who have devoted our lives to ministering to them."

In a follow-up on the same topic, the Aug. 10 Mobility Matters featured a Q&A with well-known clinician Mark R. Schmeler, PhD, OTR/L, ATP, about the PWC documentation process. Schmeler is an Assistant Professor in the Department of Rehabilitation Science & Technology at the University of Pittsburgh with over 20 years of experience in the field.

According to Schmeler, "Physicians in this situation should be referring these cases to rehabilitation specialists such as physiatrists and/or occupational and physical therapists, since this is what we do. But the policy is not completely clear this is an appropriate and acceptable referral pathway." He noted that some physicians might not understand the complexity of the PWC coverage policy. "It is not that we as clinicians are not smart people, it is just that there seems to be a higher level of complexity to the documentation and provision of a power wheelchair or scooter that addresses pretty obvious needs compared to other similar interventions like artificial limbs or braces."

The process becomes even more burdensome when a home care provider is worried about Medicare reimbursement, Schmeler said: "The patient may have an obvious need for a power wheelchair, but the home care provider asks that the documentation be modified or redone by the clinicians so that the case is stronger. This creates added frustration and delays. Clearly, there is a considerable gap between the intent of the documentation policy and the criteria utilized by auditors who search for any small or insignificant reason to deny claims."

Schmeler pointed out that a swing from one extreme to the other — from "vague policy with little accountability for many years to a lot more accountability and restrictive policies that has been hard to digest and implement" — could be "delaying, or even preventing," Medicare patients from receiving the power wheelchairs they need.

Schmeler's conclusion: "The bottom line is this: we have a growing population of people with mobility limitations who want to remain active participants in their homes and communities. The spirit of our nation is to allow them to keep their freedom and independence and not be stuck in a nursing home. Powered mobility is an obvious viable option for many — we just need to figure out a way to provide this in a reasonable manner that ensures those who need powered mobility get it without too much burden. The government, industry, clinicians, and consumers each have a role and stake in finding this balance. CMS is certainly in the position with the most power to facilitate these changes through appropriate policy guidance."

To read the full issues of Mobility Matters, check the AAHomecare website.