New Power Mobility Guidance Issued

COLUMBIA, S.C.–The Region C DME Medicare Administrative
Contractor published its latest documentation guidance for power
wheelchairs and scooters late Tuesday night.

While the guidance mainly repeats information that has already
been released in the current local coverage determination and other
DMERC publications on power mobility devices, there are some new
requirements that will take effect Aug. 24.

Since CMS announced last year that it was eliminating the
certificate of medical necessity (see HomeCare Monday, Aug. 29, 2005) and
later issued its final power mobility rule, which went into effect
June 5 (see HomeCare Monday, April 10), mobility
providers have been waiting for additional information on what
documentation is required to support PMD claims. When CMS
eliminated the CMN, it also required that physicians supply
providers with a prescription and patient records that prove
medical necessity for power equipment within 45 days of a
face-to-face exam.

Following release of the latest information, however, some
stakeholders say they still are not exactly clear on what
documentation should be requested and kept in the patient file.

“We think it’s a missed opportunity to provide some objectivity
and clarity in the process,” said Eric Sokol, director of the Power
Mobility Coalition, adding that a template or guidelines would be
helpful in assuring providers that “if x, y and z is done,” they
will be reimbursed for their claims.

One new requirement that concerns some stakeholders is that the
diagnosis of certain conditions will be emphasized over the
face-to-face exam in the patient’s medical record. “For example,
for patients with [chronic obstructive pulmonary disease], heart
failure or arthritis, the major emphasis will be on symptoms and
history of the progression of their condition rather than on the
physical examination,” according to the new guidance.

“Singling out certain diagnosis codes and treating them
differently de-emphasizes the face-to-face [physician’s
examination],” Sokol said. “It’s totally subjective.”

Seth Johnson, vice president, government affairs, for Exeter,
Pa.-based Pride Mobility Products and chairman of the American
Association for Homecare’s rehab council, also said he is concerned
about what appears to be a “two-tier standard” based on
condition.

“This is almost counter to congressional intent,” he said.
“Congress mandated that the face-to-face exam occur to justify
medical necessity for an item.”

Another new requirement is that prior to delivery, providers
must have a physician sign a detailed product description that
lists the specific HCPCS code for the equipment along with the
manufacturer name and model, options and accessories.

Because providers must receive all documentation from the
physician within 45 days of the patient exam, this additional
requirement compounds paperwork and probably means another contact
with the physician’s office, Johnson said, adding that getting all
that done within the timeframe required could prove difficult.

“A lot of times the decision as to what specific power
wheelchair base will be used may not be decided until a few days
prior to delivery,” said Johnson. “It’s going to require suppliers
to have to go back to the physician [for another] signed and dated
document. It’s an additional burden on physicians and an additional
burden on suppliers.”

Key points included in the guidance:

• Providers must date-stamp all documentation upon receipt from
  the physician. The 45-day timeframe for providers to receive the
  documentation upon completion of the physician face-to-face exam is
  reiterated.
• Providers must prepare a written document that lists the
  specific base with the HCPCS code and manufacturer name/model, and
  all options and accessories that will be separately billed.
• For claims with dates of service on or after Aug. 24, 2006,
  providers must list their charge and the Medicare fee schedule
  allowance for each separately billed item. The physician must sign
  and date this detailed product description, and the provider must
  receive it before delivery of the PMD.
• For claims with dates of service on or after Aug. 24, 2006, the
  PMD delivery must occur within 120 days of the face-to-face
  exam.
• Physicians must document the patient evaluation in a detailed
  narrative note in their charts in the format that they use for
  other entries. The guidance states that even if the physician
  completes a provider-generated form and puts it in his/her chart,
  this is not a substitute for the comprehensive medical record.
• Physicians may refer the patient to a licensed/certified
  medical professional who has experience and training in mobility
  evaluations to perform part of the face-to-face exam. This
  individual may not be an employee of the HME provider or have any
  financial relationship with the provider. (There is an exception:
  If the provider is owned by a hospital, an LCMP working in the
  inpatient or outpatient hospital setting may perform part of the
  face-to-face examination.)
• If the report of an LCMP evaluation is to be considered as part
  of the face-to-face exam, there must be a signed and dated
  attestation by the provider that the LCMP has no financial
  relationship with the provider. This requirement will be enforced
  on claims that are received by the DME contractor on or after Aug.
  10, 2006. The guidance notes that evaluations performed by an LCMP
  who has a financial relationship with the provider may be submitted
  to provide additional clinical information but will not be
  considered as part of the face-to-face examination by the
  physician.
• The guidance notes that even if an LCMP performs a major part
  of the mobility evaluation, there still must be a face-to-face exam
  by the physician.
• In the event the DME Program Safeguard Contractor asks for
  documentation on individual claims, additional documents (e.g.,
  notes from prior visits, test reports, etc.) also must be obtained
  from the treating physician to provide a historical perspective
  that reflects the patient’s condition, corroborating the
  information in the face-to-face examination, and painting a picture
  of the patient’s condition and progression of disease over
  time.

A link to the Palmetto GBA document is available by clicking here.