CMS Electronic Clinical Template: A Work in Progress
- By Julie Piriano
- Sep 01, 2012
On the power mobility device
(PMD) Prior Authorization
(PA) Demonstration Open Door Forum
call March 28, the Centers for Medicare & Medicaid Services (CMS) surprised the
industry when it announced it was developing
an electronic clinical medical necessity
template. The template “would allow
electronic health record vendors to create
prompts to assist physicians when documenting
the Power Mobility Device face-to-face encounter for Medicare purposes.”
Since that time, CMS has conducted
three special open door forum calls (ODF)
on April 10, June 14, and July 10 to solicit
input as to what data elements stakeholders
recommend for inclusion in the development
of this electronic clinical template, or physician prompted electronic
health record. While it is becoming increasingly clear that this
is not a short-term initiative, CMS does seem to recognize the clear
need for a tool to help physicians document the medical information
Medicare wants to evaluate in making a coverage determination.
Is a Final Version on the Horizon?
In mid-July, CMS posted version 9.6 of the “Suggested Electronic
Clinical Template Elements of a Progress Note Documenting a
Face-to-Face PMD Examination” to its Web site and indicated on
the ODF call July 10 that this is nearing finalization. As part of the
background information provided with v9.6, it states the “document
describes the data elements that CMS believes would be useful
in supporting the documentation requirements for coverage of a
PMD.” In addition, it reminds physicians and treating practitioners
that “documentation of the face-to-face examination should accurately
refl ect the patient’s individual condition(s) that necessitate
the use of a PMD. As such not all data elements will be applicable to
all patients, and answers to all of these data elements in any given
record would not generally be expected.”
This is good as long as CMS clearly specifies what is required when
this initiative enters the next phase and is ultimately incorporated into
electronic health record (EHR) soft ware vendor systems. However,
under the current system, this is particularly concerning to PMD
providers who must rely on a complete and comprehensive medical
record to compliantly bill and receive payment for the PMD and to
ensure they retain their reimbursement in a post-claim audit.
As a result, stakeholders have requested CMS not only identify the
data elements that would be required for all patients, but also define
what constitutes the mobility evaluation that can be completed by a
physical or occupational therapist as part of the face-to-face process.
This should significantly reduce the types of documentation errors
and omissions identified in numerous widespread audits where the
Durable Medical Equipment Medicare Administrative Contractors
(DME MACs) continue to conclude:
- There was insufficient evidence that a physician face-to-face
mobility exam occurred. Requested medical records did not
establish medical necessity, or documentation available from
the mobility exam was insufficient; it did not objectively address
mobility limitations and provide a clear picture of the patient’s
- The face-to-face examination did not support that the beneficiary
required power mobility in order to complete mobility-related
activities of daily living (MRADLs) within the home.
- The face-to-face evaluation did not provide a measurable assessment
of upper-extremity strength and function, so the reviewer
could not rule out that the beneficiary was unable to use an optimally
configured manual wheelchair.
- Clinical documentation frequently failed to address the possible
use or trials of other alternative mobility assistive devices.
While CMS has indicated the documentation requirements have
not changed and will not be changing, it is apparent that medical
professionals are not currently charting the face-to-face encounter
in accordance with what the medical reviewers expect. This is
evident by the fact that the DME MACs have reported claim denial
rates between 48.3 percent and 82 percent in their widespread prepayment
review audits for the first quarter of 2012. They further
reported that between 32 percent and 65 percent of these denials
were due to the reasons outlined above.
With an electronic clinical medical-necessity template, stakeholders
estimate that initial claims error rates will decrease dramatically
and be more in line with the percentage of claims ultimately
paid once the initial denial is overturned through appeals. This
helps providers with their cashfl ow, but also reduces CMS expenditures
by appropriately adjudicating the claim upon initial review.
Prior Authorization Demonstration Project
The opportunity for CMS to make an appropriate determination
upon initial review is further enhanced for PMD providers and
Medicare beneficiaries in California, Florida, Illinois, Michigan, New
York, North Carolina and Texas, where the PMD prior authorization
demonstration will be conducted starting Sept. 1. Once the template
is available for use, the reviewers who previously determined a beneficiary’s medical records were insufficient to warrant payment for the
PMD after they received the device will be able to adjudicate the PA
request in a clear and consistent manner. Until such time it is likely these same reviewers will deny a similar percentage of prior authorization
requests for lack of medical documentation, thereby denying
access to care for seniors and people with disabilities until the documentation
discrepancies are resolved.
Unfortunately, CMS has said the PA demonstration and the development
of an electronic clinical medical-necessity template are two
different projects that will begin independently. It stands to reason
that a standardized format for documenting and reporting medical
information will not only provide physicians and treating practitioners
with the needed guidance for properly documenting their
comprehensive evaluation; it would also allow CMS medical review
staff to adjudicate the prior authorization request for a power mobility
device in an efficient and effective manner across all contractors in the
seven demonstration states. In addition it would provide CMS with a
mechanism to test the effectiveness of the tool, and potentially make
modifications to it, prior to a national roll out.
According to Melanie Combs-Dyer, deputy director of the
Provider Compliance Group at CMS, the electronic clinical template
should help physicians “gather the right information and document
all the right things during that face-to-face evaluation.” If it is designed properly, it could also assist the physician in recognizing
when he or she should refer a Medicare beneficiary to a licensed/certified medical professional (LCMP), such as a PT or OT who
specializes in seating and wheeled mobility evaluations, to perform
a complex functional mobility evaluation.
There will be no guarantee that if a physician or treating practitioner
completes his or her evaluation and documents the findings
using the electronic clinical template that the beneficiary will meet
the coverage criteria for payment of a PMD. In fact, the template
could prompt the physician to pursue a different plan of care for his
or her patient, such as medical, surgical or therapeutic intervention.
As stakeholders in the provision of PMD, it is imperative that
physicians, clinicians and PMD providers weigh in with CMS on
the value of a clinical medical necessity template. However, it is
critical for CMS to address the identified physician documentation
issues and ensure the template includes appropriate data elements
for the medical evaluation, defines the mobility evaluation and
includes prompts to alert the physician or treating practitioner
when a referral to a licensed and certified medical professional for
a complex functional mobility evaluation is appropriate or highly
recommended. An appropriately designed clinical template should
help CMS more clearly outline for all stakeholders what constitutes
a mobility evaluation.
This article originally appeared in the September 2012 issue of Mobility Management.
About the Author
Julie Piriano, PT, ATP/SMS, is VP, Clinical Education, Rehab Industry Affairs & Compliance Officer for Pride Mobility Products.