Clinically Speaking

CMS Electronic Clinical Template: A Work in Progress

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 mobility deficits.
  • 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.

Independent Projects

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.

In Support of Upper-Extremity Positioning