New PMD Guidance Concerns Stakeholders

Washington

Following the DMERCs’ and Medicare Administrative Contractors’ release of the latest power mobility device guidance, some stakeholders say they still are not exactly clear on what medical documentation providers should request and keep in their patients’ files to support claims.

“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.

While the guidance mainly repeats information that has already been published, the 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 [exam],” Sokol said. “It’s totally subjective.”

Seth Johnson, vice president, government affairs, for Exeter, Pa.-based Pride Mobility Products, 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 the PMD delivery must occur within 120 days of the face-to-face exam. And prior to delivery, providers must have the prescribing 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.

“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,” Johnson said.

For more, see “Washington Wit & Wisdom” on page 48.

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.

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 and later issued its final power mobility rule, which went into effect June 5, 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.

Hanna, Cherney Join Editorial Advisory Board

Atlanta Alison Cherney and Sarah Hanna are the newest members of HomeCare’s Editorial Advisory Board. Cherney, who contributes “Selling Tips” for HomeCare, is president of Brentwood-Tenn.-based Cherney & Associates, a marketing and sales consulting firm. She also is the producer of Homecare Power Selling, a sales training program for home care sales reps. Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio. She writes “Downsize Those DSOs,” a monthly feature in HomeCare.