PMD Prior Authorization

In late January, the Office of Inspector General (OIG) issued “Medicare Paid Suppliers for Power Mobility Device Claims That Did Not Meet the Federal Requirements for Physicians’ Face-to-Face Examinations of Beneficiaries,” the sixth OIG report in as many years focusing on the sufficiency of medical documentation for power mobility device (PMD) claims. This OIG report, however, focuses on physician use or nonuse of the G0372 billing code, which indicates that all information necessary to document the PMD prescription is included in the medical records and that all necessary documentation has been delivered to the DME supplier. The OIG looked at the Medicare program’s optional G0372 code and concluded that PMD claims without this code were far less likely to have medical documentation that met the Medicare PMD face-to-face examination documentation requirement. In 2010, 6 percent of PMD claims were associated with a physician billing the code. The OIG looked at paid claims data for PMDs ($576 million), culled $84 million in claims for other issues, matched the remaining claims to physician-billed G-code claims, then separated those where the G-code was billed by the prescribing physician versus another physician. From the 7,187 PMD claims with corresponding G-code claims, the OIG randomly selected 100 PMD claims for review. From the 164,300 PMD claims without corresponding G-code claims, the OIG removed 133,776 PMD claims that had a corresponding “evaluation and management” service provided by the prescribing physician within 120 days before delivery of the PMD. The OIG considered the remaining 30,524 PMD claims as high risk, and from these claims they randomly selected 100 claims for review. Of these 100, 53 claims met the requirements. For the 47 claims that didn’t, the physicians did not conduct the required face-to-face examinations for 19, and the physicians’ medical records did not meet the minimum documentation requirements for 28. In a not too startling observation, the OIG concluded that many physicians were unfamiliar with the G0372 code, and that many physicians were not aware of the documentation requirements for face-to-face examinations. The OIG reached this conclusion, not just by observing medical records, but also by interviewing physicians. As a result of these observations, the OIG made several recommendations to CMS, including: (1) require physicians to use the G0372 billing code (and stating that any increased expenditures here would be more than offset by a significant reduction in paid PMD claims); (2) require Medicare Part B contractors to educate physicians on the use of G0372 code and documentation requirements for the face-to-face examination requirement. In an interesting response, CMS disagreed with these two OIG recommendations. CMS stated that its “3-year demonstration program testing the use of prior authorization for PMDs reduced Medicare expenditures for PMDs and was a better alternative for ensuring accurate payment of PMD claims than requiring use of the G0372 code.” CMS also rejected the OIG’s recommendations to educate physicians: “CMS stated that it did not believe efforts to educate physicians on the use of the G0372 code were appropriate and that the use of prior authorization was the most ideal method to ensure physicians conduct required face-to-face examinations and supply all necessary documentation to suppliers.” One peculiar aspect of CMS’s response: in a prior authorization process physicians would still have to be educated on the correct billing and documentation associated with physician use of the G0372 code, because the prior authorization demonstration uses the same coverage and documentation requirements. The CMS prior authorization demonstration is slated to end Aug. 31. Last summer, CMS issued a proposed rule to establish a prior authorization program for many items of DME, but at press time had yet to finalize. It is theoretically possible that CMS could establish a permanent prior authorization process for PMDs that could start nationwide by Sept. 1. Another observation: In following up with one sample of PMD claims, 10 of 16 suppliers the OIG contacted were out of business; the OIG conducted this followup in 2013 based on 2010 paid claims. Finally, the OIG does not identify a significant reason physicians don’t use the G0372 billing code—that payment is only about $21 and therefore not worth billing, or actually complying with the extensive documentation requirements.