Documentation Rules

There is no question that the new national coverage policy for power wheelchairs and scooters is vastly improved from the antiquated “bed- or chair-confined” standard that has been Medicare policy since any of us can remember. Granted, there are still limitations such as CMS’ “in-the-home” restriction, and questions about how the four DMERCs will explain and amplify the national policy in their local policy.

But now we need to talk about the issue that is all-important to any supplier providing mobility equipment: What documentation will be deemed to be appropriate and useful in the event of a pre-or post-payment audit?

The new national policy — formally called National Coverage Decision for Mobility Assistive Equipment (MAE) — is based upon a series of function-based questions. The policy covers canes, crutches, walkers and manual wheelchairs as well, contemplating that the prescribing physician will go through a logical progression of questions to prescribe the most appropriate medical device.

All this is good. But even the best-drafted national coverage policy would not be effective unless CMS and the DMERCs provide detailed guidance to suppliers about the appropriate types of documentation and information necessary to substantiate a beneficiary’s need for the mobility device.

For that reason, the Restore Access to Mobility Partnership has provided recommendations to CMS and the DMERCs regarding appropriate documentation guidance, founded on the following principles:

1. Medicare Part B suppliers need to have appropriate and consistent national directives regarding what is appropriate documentation to substantiate medical need for a mobility device such as a power wheelchair. Without such directives, suppliers will not be able to provide medically necessary items, because there will be no guidance regarding what types of information will be necessary to substantiate medical need.
2. Given the complexity of determining medical necessity, CMS should acknowledge that physicians do not and will not, as a matter of practice, document the beneficiary’s medical condition in the medical record with the level of specificity envisioned in the national coverage policy.
3. The documentation requirements must be tied directly to the coverage policy and clearly outline the required information, who is responsible for providing the information and how the information must be documented.
4. The documentation requirements must specify what documentation will be accepted as a definitive determinant of medical necessity absent fraud.

In providing these recommendations, RAMP made the following assumptions:

• Physicians will be required to conduct a face-to-face examination of the beneficiary prior to prescribing a power wheelchair, pursuant to a forthcoming regulation that will be issued by CMS. (At press time, CMS had yet to issue this regulation.)
• The DMERCs’ local medical policy will provide further clarification of the national policy. These clarifications should be incorporated into the documentation guidance, including a new certificate of medical necessity and optional questionnaire.

Recommendations

• CMS should develop a new CMN that includes the detailed coverage rules of the new national Medicare coverage policy for MAE.
• CMS should require prescribing physicians to send electronically the completed CMN and the relevant portions of the beneficiary’s medical record to the supplier, at the time of prescription.
• In lieu of the medical record, a licensed clinician should be able to evaluate the beneficiary’s need and document the beneficiary’s condition/needs as they relate to the NCD. This information need not be in a required form; rather, CMS and/or the DMERCs can provide a suggested series of questions that need to be addressed. Those questions should be based on the NCD.

A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her by phone at 440/329-6226 or by e-mail at [email protected].

Note: The RAMP coalition includes the American Association for Homecare, Invacare Corp., The Med Group, Mobility Products Unlimited, Pride Mobility and Sunrise Medical.