Coverage Criteria: CMS Clarifies PMD "Rules of the Road"
- By Julie Piriano
- Aug 01, 2011
In early May, CMS published a Special
Edition (SE1112) Medicare Learning
Network (MLN) Matters article titled Power
Mobility Device Face-to-Face Examination
Checklist for physicians or treating practitioners
who prescribe power mobility
devices (PMDs) for Medicare beneficiaries.
It is both interesting and a bit frustrating
that CMS has released this clarification on
the “Rules of the Road” nearly six years
after the National Coverage Determination
(NCD) for mobility assistive equipment was
enacted to “improve compliance with documentation
requirements for the face-to-face
examination that occurs prior to the physician
or treating practitioner ordering a PMD
for their Medicare patients.”
The publication states, “an in-person
visit between the ordering physician and
the beneficiary must occur,” and that “this visit must document the decision
to prescribe a PMD.” It further states, “The evaluation must clearly
document the patient's functional status with attention to conditions
affecting the beneficiary's mobility and their ability to perform activities
of daily living within the home.” It still does not indicate exactly what this
means; however, the following may be helpful when educating referral
sources as to why the beneficiary requires the use of a PMD to accomplish
Mobility Related Activities of Daily Living (MRADL).
Understanding Mobility Limitations
MRADL is a Medicare term that describes the movement from point A to
point B in order to perform an activity in the customary location of the
home throughout the day. It is not intended to consider the beneficiary's
ability to perform the activity itself.
In addition, a mobility limitation is not diagnosis driven. It is demonstrated
when the individual is not able to move to or from the location
of an activity independently, safely or in a timely manner. The PMD Local
Coverage Determination defines a mobility limitation as one that:
- Prevents the beneficiary from accomplishing the MRADL entirely, or;
- Places the beneficiary at a reasonably determined heightened risk of
morbidity or mortality secondary to the beneficiary's attempts to participate
in MRADLs, or;
- Prevents the beneficiary from completing the MRADLs within a easonable
A closer examination of these concepts may make the new checklist
more helpful when educating referral sources.
Independence – Individuals who require the presence of a caregiver
when moving from point A to point B are not independent, regardless of
how far they can walk or push a manual wheelchair. Any level of dependence
on another person prevents the beneficiary from accomplishing the
MRADL entirely in the absence of their caregiver. This is especially important
to remember for individuals who have progressive conditions that have
not yet progressed to the point of being non-ambulatory.
During the evaluation, the physician or clinician may document the
distance their patient is able to ambulate or self-propel with assistance, but it
is more important for the documentation to indicate how far they can ambulate
or propel without assistance. If therapeutic intervention will achieve
independence, then the provision of a PMD would not be appropriate.
Safety – Anything that places the beneficiary at reasonably determined
heightened risk of morbidity or mortality secondary to the attempts to
participate in MRADLs is a risk to their safety. A beneficiary whose current
means of mobility is deemed medically contraindicated or places them at
risk for falls or musculoskeletal injury has a valid mobility limitation. This
may be due to a chronic medical condition, aging with a disability or both.
If medical or surgical intervention will resolve the cause of the limitation,
then a PMD would not be warranted. A beneficiary receiving therapy
services to resolve compromised balance, strength, range of motion,
muscle tone or coordination issues, with their current means of mobility,
would not be a candidate for a PMD, either.
Timeliness – When a mobility limitation prevents the beneficiary from
completing their MRADLs within a reasonable timeframe, you may find the
beneficiary plans their day around toileting or forgoes nutrition and hydration,
dressing or daily grooming and hygiene because it takes too much
out of them. The time it takes for an individual to move between two fixed
points with their current mode of mobility can be quantified. If a medical,
surgical or therapeutic intervention to reduce energy expenditure and
increase the beneficiary's speed, efficiency and endurance will not improve
the timeliness of their ambulation or self-propulsion over the surfaces they
encounter in their home, then there is a mobility limitation that could be
resolved with the provision of a PMD.
Getting the Timing Right
SE1112 reminds us that the evaluation and documentation “may be done
all or in part by the ordering physician. If all or some of the medical examination iscompleted by another medical professional, the ordering
physician must sign off on the report and incorporate it into their records.”
The culmination of this process constitutes the face-to-face exam after
which the ordering physician may write the prescription for the PMD. “This
prescription has seven required elements and is referred to as the sevenelement
order, which must be entered on the prescription only by the physician,”
according to the article. It should not be written before the physician
has all the information to make the decision that the provision of a PMD is
the best course of medical care for a patient.
The supplier must receive the records of the face-to-face examination
and the seven-element order within 45 days. They must also date stamp
receipt of these documents to confirm they were received within this timeframe.
Upon receipt of the documents, the supplier should review the
documentation to ensure the medical necessity for the provision of the
PMD is established, as documents and documentation are not the same
things. Under the Tips to Avoid Denial of PMD Claims, SE1112 lists several
questions to help suppliers educate the medical community so that their
documentation substantiates the medical need for a PMD. It also provides
an example of a detailed narrative note, which must be “in the format that
they use for other entries,” per the PMD LCD.
Once the specific PMD and options are determined, the supplier must
prepare a detailed product description for the physician to sign, date and
return prior to delivery. Effective June 1, 2011, “This Detailed Product
Description (DPD) must comply with the requirements for a detailed written
order as outlined in the Supplier Manual and CMS' Program Integrity
Manual [PIM] (Internet-Only Manual, Pub. 100-08) Chapter 5. The description
must provide sufficient detail to identify the items in order to determine
that they (were) properly coded,” according to the PMD LCD. While
SE1112 does not provide any information regarding the DPD, it should
be noted that the “Rules of the Road” for this document changed, as
the policy no longer lists the elements, such as the HCPCS code, narrative
description of the item, manufacturer name, product make and model,
supplier's charge and Medicare fee schedule allowance, required to be
part of a “compliant” DPD. Instead, it “must clearly specify the start date
of the order,” include “all options or additional features that will be separately
billed or that will require an upgraded code” with “either a narrative
description or a brand name/model number,” per section 5.2.3 of the PIM.
As a result of industry pressure and the claims denial rates of power
wheelchair audits over the past several years, CMS appears to recognize
that the “Rules of the Road” were not as crystal clear as originally anticipated.
Time will tell if this additional clarification on what is outlined in
the NCD, Power Mobility Device Local Coverage Determination and Policy
Article will be helpful in assisting suppliers in educating their referral
sources and ensuring their files are compliant in the event of an audit.
This article originally appeared in the August 2011 issue of Mobility Management.
Julie Piriano, PT, ATP/SMS, is VP, Clinical Education, Rehab Industry Affairs & Compliance Officer for Pride Mobility Products.