Exactly What Documentation Does Medicare Want?

Paper Chase

Many people have requested detailed instructions on what Medicare would deem to be appropriate documentation for payment of power mobility devices (PMDs). The Centers for Medicare & Medicaid Services (CMS) has now provided a "clarification." Certain details create questions; however, I have to admit that much of it makes sense and is not much different than what many providers are already doing.

A provider must deliver a PMD within 120 days of the face-to-face.

To keep this simple, I have broken it down into pieces. Keep in mind that this information discusses the general requirements. CMS also provided more specific Advance Determination of Medicare Coverage (ADMC) requirements, which we'll discuss at a future time.

Documentation & Date Stamps

A couple of months ago, CMS made one change regarding the Interim Final Rule (IFR). This change requires providers to receive a copy of the report of the face-to-face evaluation of the patient's mobility needs within 45 days of completion of that evaluation (this was changed from the previous 30 days). Remember that the "clock" for these 45 days starts ticking at different times depending on whether or not a patient is referred to a physical or occupational therapist for a seating/wheelchair evaluation.

As for the actual documentation required, first is the written order from the treating physician. This order must contain seven items:

  1. Beneficiary's name
  2. Description of the item that is being ordered (this may be general)
  3. Date of the face-to-face examination
  4. Pertinent diagnosis/conditions related to the need for the PMD
  5. Length of need
  6. Physician's signature
  7. Date of the physician's signature

As a provider, you need to be certain to date stamp the document when you receive the it. The instructions do state a "date stamp" or its "equivalent." Once the actual product is selected for the client, the provider needs to prepare a "Detailed Product Description." In essence, you will now be completing Section C of the old Certificate of Medical Necessity (CMN). The CMN form is gone; however, CMS still wants all the same information.

This detailed product description must contain HCPCS codes, manufacturer name and model of the base, and all options and accessories. It also must contain your charge and the Medicare fee schedule (this is required for dates of service on or after August 24, 2006). Just like the requirements on the old CMN, if there is not an allowable, just write "Not Applicable" next to the corresponding line item. This form must also be signed by the physician, but only needs to be received prior to delivery (not within the 45-day time span). Again, be sure to use a date stamp to confirm when you received this form.

Delivery in 120 Days

Next, we move on to a "new" requirement regarding when products have to be delivered. Truthfully, this is not completely new. There was a similar requirement when we had the CMNs in place.

CMS has stated that a provider must deliver a PMD within 120 days of the face-to-face evaluation. When you look at the norm, this should not be a problem. This is especially true when considering that orders that may take this amount of time to complete are high-end/complex rehab orders. In these cases therapists are involved in completing the evaluations, so the "clock" will not start ticking until the physician actually signs and concurs with the evaluation.

If you think this through, it actually makes some sense. Medicare is not stating that they will not cover the product for the client; they only want to make sure that the client is receiving the appropriate equipment. They believe (and it is true in many cases) that a client's condition may change as time passes, which in turn may affect the "setup" or selection of the product originally ordered.

As for documentation, the industry asked for clarification, and CMS delivered. Ironically, it is not exactly what the industry wanted. Since the National Coverage Determination (NCD) went into effect and the algorithmic approach was introduced, prepared "forms" or "questionnaires" were developed by both providers and manufacturers. These forms were created in hopes of assisting physicians in documenting the medical need of a PMD and allowing providers to feel that they would be protected under the documentation requirements. Simply put, it is not enough. When I read through the clarification, I hate to admit it makes sense. A key word discussed is "progression." CMS also pointed out examples (note the word "examples," not all inclusive) of diagnoses where they would expect to see a progression of the condition leading to the need of a PMD.

Sit back and think through a common situation. Geriatric clients who have Chronic Obstructive Pulmonary Disease (COPD), Congestive Heart Failure (CHF), or osteoarthritis typically do not wake up one morning with no ability to ambulate functionally throughout their homes. These conditions start and then may progress to the point of not allowing a patient to function within his home. The key is that it takes some time; obviously, the timeframe varies from patient to patient. But again, the typical route with these conditions is that they are first diagnosed, and then treatments are tried. At a minimum the patient is followed, meaning there are notes within the chart of a patient who has seen the doctor and been looked at for that specific condition. Older notes may not be perfect, but from what I have found, I can usually see how the patient ended up with a need for a PMD.

Seating Evals & Clinicians

Finally, there is the issue of seating evaluations conducted by physical or occupational therapists. Many of you have these completed on the majority of your clients. Life should not change dramatically for you unless the therapists were paid by you (or were financially tied to you) for the evaluations. At Orion, I have always said it was fine for you to employ therapists, but that their paperwork would not back you up in the eyes of Medicare. This still holds true. Any evaluation conducted by a therapist must have a signed attestation declaring that he or she has no financial tie to you, the provider.

With all this new information, do not just panic and feel as if your PMD business is doomed. Many of you have already been performing a majority of these actions, but just in a different manner. I believe people react more intensely when it is in writing rather than looking back and realizing it makes some sense and that they just have to put some last checks in place. With some of this information, you may even have a leg up on your competition.

Keep in mind: The changes will continue, so stay up to date.

This article originally appeared in the September 2006 issue of Mobility Management.

In Support of Upper-Extremity Positioning