Open Door Forum: Will PMD Electronic Template Work?

At the June 14 Open Door Forum about an electronic template for face-to-face power mobility device exams, a theme emerged among the providers who participated in the question-and-answer session:

It's a good idea in theory, but is it practical, and will it work?

The Centers for Medicare & Medicaid Services (CMS) conference call was held to discuss the "data elements" that would be included in the clinical template. The goal of the template is to help physicians and other clinicians to develop adequate and appropriate documentation to medically justify the power mobility devices (PMD) they're prescribing.

Barbara Cebuhar - from CMS's Office of Public Engagement - chaired the call.

Melanie Combs-Dyer, deputy director of the provider compliance group, was the main speaker, and Combs-Dyer advised Open Door Forum attendees to refer to draft v9.4, available as a pdf download.

The draft is divided into eight sections, starting with Chief Complaint, and followed by History of Present Illness, Past Medical History, Social History, Review of Symptoms, Physical Exam, and Patient Assessment.

The draft concludes with Plan ("Indicate intent to order PMD") and information about the physician or treating practitioner, including name, credentials, national provider identifier (NPI), and the date of the required face-to-face examination. The most recent draft, posted June 13, also included beneficiary information and the seven-element order within the Plan section.

The template version discussed in the June 14 Open Door Forum was 6.5 pages long.

An Additional Tool for Prescribing Physicians

"We believe that this electronic clinical template project may help some physicians and treating practitioners gather the right information and document all the right things during that face-to-face evaluation," Combs-Dyer explained during the call. "We're just trying to give the physicians and treating practitioners an additional tool they can use."

She added that no documentation or coverage criteria would be added or affected by the creation of the template.

"Once we think we have the finalized set of data elements, the plan is for CMS to turn over that list of electronic clinical template data elements to the Office of the National Coordinator for Health IT (ONC)," Combs-Dyer said. "ONC will take it from there in terms of taking those data elements and developing the electronic standard that will allow for the data elements to be built into electronic health records, and to be able to be moved from, for example, the physician to the supplier, or from the supplier into CMS in a structured way."

Using the form will be optional, Combs-Dyer said.

The purpose of this particular Open Door Forum was to discuss which specific measurements, medical facts and patient details should be included in the template.

But providers calling in during the question-and-answer period quickly indicated they had broader concerns about the template.

Will Physicians Use the Electronic Template?

Multiple conference call attendees mentioned the length of the template.

Kim Ross, from the Texas Academy of Family Physicians, said, "Our initial take is that the length is somewhat daunting, and we're not sure as yet if it will help move the needle in the way of reducing documentation error."

A provider asked how long it would take physicians to complete a face-to-face exam using the current version of the lengthy template.

"If you had to address each and every point on this template," the provider asked, "how long do you think that would take for you to do that evaluation?"

Both Dr. Robert Hoover (medical director, Jurisdiction C) and Dr. Paul Hughes (medical director, Jurisdiction A) said lengths of face-to-face exams would vary widely according to the habits of the practitioner and the needs of the individual patient.

Hughes added, "The medical examination that is required to be done as part of a power wheelchair evaluation is envisioned by the policy and we believe by the statute to be a fairly comprehensive physical examination."

"I don't think it's envisioned," Hoover said, "that every one of the points in this electronic template would have to be covered with every single patient. We make a similar point in our LCD (local coverage determination) when we say the evaluation should be tailored to the individual patient."

Combs-Dyer mentioned it might be possible to add a note to the template to explain that not every data element would need to be completed during every face-to-face exam.

But the next Q&A caller said, "As an equipment provider, we can't have issues with doctors not giving us enough information to qualify. So if you add a note saying that they don't have to complete everything (on the template), we may not get enough information."

The caller also asked if there was any timeline for when the template would go into use.

Combs-Dyer said, "I don't know, but I would guess that we are still many months away... This is not something that's going to be done in the next couple of months. I would not expect it would be done in the next six months."

Concerns About Documentation Continue

While CMS personnel leading the call tried repeatedly to limit the Open Door's discussion to which pieces of information the template should ultimately ask for, providers repeatedly referred to the template's bigger picture.

One caller asked about physician reimbursement for completing the template, and expressed concern that relatively low reimbursement amounts would not motivate doctors to complete it.

"Basically, it's a comprehensive exam; it's a complex visit," he said. "Because this is a (six-and-a-half-page) assessment - and you would assume that any patient who comes in with this kind of problem has a lot of co-morbidity - to get them to complete this form, they're going to want to be compensated for it. I'm hoping that's incentive for them to see that this information will be completed rather than partially completed and then denied."

Another caller questioned CMS's plans to educate physicians about the template: "What is going to be the educational process for those physicians who don't have the time to attend these types of forums?"

Combs-Dyer said after the template is rolled out, CMS is "making the assumption that they will be relatively user friendly and easy for physicians and treating practitioners to understand, and they will be sort of seamless."

The caller replied, "I was literally on the phone today with physicians with one of the Mayo facilities, and of course, they didn't have any idea about any of this. Where can I direct them to have some more education on all this? (The template is) obviously considerably more involved and more detailed than I think most physicians believe the face-to-face is currently."

Said Combs-Dyer: "We certainly want to do as much education as we possibly can to physicians about this clinical template, and we would welcome if you have suggestions on ways we can reach out to physicians. We certainly are going out on our list-serv and our other vehicles we use to communicate to physicians about this electronic clinical template, but if you have other ideas, we would absolutely welcome them."

While CMS personnel encouraged providers and other stakeholders to continue to send suggestions about the template (eclinicaltemplate@cms.hhs.gov), it was clear that providers on the call were weary and frustrated by the long struggle to figure out what documentation would satisfy DME MACs as well as the many different CMS auditors that might examine a claim along the way.

"I'm just kind of surprised," said one caller, "that the question is 'What data elements should we be asking for in this new form?' - since that's the question that, as a small supplier, we are constantly asking Medicare to help us determine.

"We see these huge numbers and percentages of audits that are denied for non-medical necessity, for documentation not being good enough. Frankly, we're at the point that we've practically given up getting anything from a doctor that is adequate enough to meet Medicare's audits and show somebody needs a power wheelchair. The doctors don't know what to do."

She added, "No doctor who does two power wheelchairs a year is going to read the power wheelchair LCD. You say you're surprised they don't know what their options are. This is such a tiny piece of their practice; why would they know what their options are? I think there's a bigger problem here, that people are having trouble getting the correct documentation from the doctor to support a power wheelchair."

The next Open Door Forum on the electronic clinical template is July 10.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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