Funding Essentials

Coverage Criteria: CMS Clarifies PMD "Rules of the Road"

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 timeframe.

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.

About the Author

Julie Piriano, PT, ATP/SMS, is VP, Clinical Education, Rehab Industry Affairs & Compliance Officer for Pride Mobility Products.

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