Archive for the ‘Complex Rehab DME Reimbursement’ Category

Power Wheelchairs and Power Operated Vehicles Documentation Requirements

Wednesday, October 19th, 2011

Dear Physician,

In order for Medicare to provide reimbursement for a power wheelchair (PWC) or power operated vehicle (POV) (scooter), there are several statutory requirements that must be met:
1. There must be an in-person visit with a physician specifically addressing the patient»s mobility needs.
2. There must be a history and physical examination by the physician or other medical professional (see below) focusing on an assessment of the patient»s mobility limitation and needs. The results of this evaluation must be recorded in the patient»s medical record.
3. A prescription must be written AFTER the in-person visit has occurred and the medical evaluation is completed. This prescription has seven required elements (see below).
4. The prescription and medical records documenting the in-person visit and evaluation must be sent to the equipment supplier within 45 days after the completion of the evaluation.
The in-person visit and mobility evaluation together are often referred to as the ≈face-to-face examinationΔ.
The complete history and physical examination typically includes:
• History of the present condition(s) and past medical history that are relevant to the patient»s mobility needs in the home:
• Symptoms that limit ambulation
• Diagnoses that are responsible for these symptoms
• Medications or other treatment for these symptoms
• Progression of ambulation difficulty over time
• Other diagnoses that may relate to ambulatory problems
• How far the patient can walk without stopping and with what assistive device, such as a cane or walker
• Pace of ambulation
• History of falls, including frequency, circumstances leading to falls, and why a walker isn»t sufficient
• What ambulatory assistance (cane, walker, wheelchair) is currently used and why it isn»t sufficient
• What has changed to now require use of a power mobility device
• Ability to use a manual wheelchair
• Reasons why a power operated vehicle (scooter) would not be sufficient for this patient»s needs in the home
• Description of the home setting and the ability to perform activities of daily living in the home
• Physical examination that is relevant to the patient»s mobility needs
• Weight and height
• Cardiopulmonary examination
• Musculoskeletal examination
Also:

Arm and leg strength and range of motion
Neurological examination
Gait
Balance and coordination

If the patient is capable of walking, the report should include documented observation of ambulation (with use of a cane or walker, if appropriate)
Examples of vague or subjective descriptions of the patient’s mobility limitations include:

• upper extremity weakness
• poor endurance
• gait instability
• weakness
• abnormality of gait
• difficulty walking
• SOB on exertion
• pain
• fatigue
• deconditioned

These types of statements are insufficient and do not objectively address the mobility limitation or provide a clear picture of the patient’s mobility deficits. Objective measurements should be provided.

The evaluation should be tailored to the individual patient»s conditions. The history should paint a picture of your patient»s functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the patient»s ambulatory difficulty or impact on the patient»s ambulatory ability.

It is important to keep in mind that because of the way that the Social Security Act defines durable medical equipment, a power mobility device is covered by Medicare only if the beneficiary has a mobility limitation that significantly impairs his/her ability to perform activities of daily living within the home. If the wheelchair/POV is needed in the home, the beneficiary may also use it outside the home. However, in your evaluation you must clearly distinguish your patient»s mobility needs within the home from their needs outside the home.
You may elect to refer the patient to another medical professional, such as a physical
therapist or occupational therapist, to perform part of the evaluation √ as long as that individual has no financial relationship with the wheelchair supplier. However, you do have to personally see the patient before or after the PT/OT evaluation. You must review the report, indicate your agreement in writing on the report, and sign and date the report. If you do not see the patient after the PT/OT evaluation, the date that you sign the report is considered to be the date of completion of the face-to-face examination.
You should record the visit and mobility evaluation in your usual medical record-keeping format. Many suppliers provide forms for you to complete. Suppliers often try to create the impression that these documents are a sufficient record of the in-person visit and medical evaluation. Based upon our auditing experience, most of them are not. That is because they typically contain check-off boxes or space for only brief answers and thus do not provide enough detailed information about the patient»s ambulatory abilities and limitations to allow the Medicare contractor to determine if coverage criteria have been met . Forms such as those developed by the Texas or Florida Academy of Family Physicians are designed to gather selected bits of information and are almost always insufficient. What is required is a thorough narrative description of your patient»s current condition, past history, and pertinent physical examination that clearly describes their mobility needs in the home and why a cane, walker, or optimally configured manual wheelchair is not sufficient to meet those needs.
You may write a prescription for a power mobility device ONLY after the visit and examination are complete. This prescription must contain the following seven elements:
1)Beneficiary»s name
2) Description of the item that is ordered. This may be general √ e.g., ≈power operated vehicleΔ, ≈power wheelchairΔ, or ≈power mobility deviceΔ√ or may be more specific.
3) Date of completion of the face-to-face examination
4) Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
5) Length of need
6) Physician»s signature
7)Date of physician signature

You must forward a copy of the face-to-face evaluation and your seven-element prescription to the supplier within 45 days from the completion of the face-to-face mobility exam. You should also include copies of previous notes, consultations with other physicians, and reports of pertinent laboratory, x-ray, or other diagnostic tests if they will help to document the severity of your patient»s ambulatory problems.
After the supplier receives your order and the face-to-face information, they will prepare a detailed product description that describes the item(s) being provided including all options and accessories. You should review it and, if you agree with what is being provided, sign, date and return it to the supplier. If you do not agree with any part of the detailed product description, you should contact the supplier to clarify what you want the beneficiary to receive.
This information is not intended to serve as a substitute for the complete DME MAC
local coverage determination on Power Mobility Devices. It is only a synopsis detailing the highlights of documentation. Refer to the complete LCD and Policy Article on the CMS Web site at www.cms.hhs.gov/mcd/overview.asp for additional information.
Medicare does provide you additional reimbursement (HCPCS code G0372) to recognize the additional time and effort that are required to provide this documentation to the supplier. This code is payable in addition to the reimbursement for your E&M visit code.
Your participation in this process and cooperation with the supplier will allow your patient to receive the most appropriate type of mobility equipment. We appreciate all your efforts in providing quality services to your Medicare patients.

Sincerely,
Paul J. Hughes, M.D.
Medical Director, DME MAC, Jurisdiction A
Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C
Adrian M. Oleck, M.D.
Medical Director, DME MAC, Jurisdiction B
Richard W. Whitten, MD, MBA, FACP
Medical Director, DME MAC, Jurisdiction D

Why the ‘Separate Benefit’ Effort Should be Supported

Wednesday, October 19th, 2011

As Laurie Watanabe, editor of Mobility Management magazine, writes in her “Liberating Complex Rehab” column, an effort to secure a separate benefit for complex rehab technology seeks in essence to more accurately identify and define both the types of equipment used by severely involved seating & mobility clients, and the clinicians and suppliers conducting the evaluations, fittings, fabrications, adjustments, client training, and service/repair. This is part one of Watanabe’s column on why the separate benefit effort should be reversed.

There is danger in being labeled something you’re not — witness the 9.5-percent Medicare funding cut to the complex rehab power category after it was carved out of future Medicare competitive bidding programs.

#1: It’s time to stop comparing apples to oranges.

It’s an old, but entirely true argument: Complex rehab technology is different than DME.

“The big picture is that complex rehab technology is a small segment of the home medical equipment marketplace, and it is used by people who have in the majority of the cases very significant disabilities,” says Don Clayback, the new executive director of the National Coalition for Assistive and Rehab Technology.

“That’s why they need this kind of equipment.”

Complex rehab is currently considered merely a type or form of DME, which means its unique factors are often overlooked or not understood. Case in point: After intensive lobbying and education efforts from the industry, complex rehab power chairs and accessories were deemed inappropriate for Medicare competitive bidding and were thus carved out of future programs. Yet, when it was time to “pay for” a July 2008 postponement of the program, complex power was included in the 9.5-percent funding cut along with the rest of the product categories involved in the failed Round 1.

“What we see happening over the last few years,” Clayback says, “is because there’s really a lack of understanding of what’s involved in this from a payor perspective or a policy-maker perspective, there’s not the necessary appreciation of the complexity of the products, the service component of the delivery model and the costs that are incurred in that process. There’s not enough awareness of that, so consequently — whether it’s coverage changes or cutbacks or competitive bidding discussions — these products get included in there, and really they’re not appropriate based on those dimensions I mentioned.”

So if complex rehab technology is not DME, what is a good comparison? Possibly orthotics and prosthetics (O&P), Clayback says, “at least to communicate what we’re trying to accomplish.” He points out that O&P is “a separate category within the DME benefit. Orthotics and prosthetics are treated differently because they’re individual to the user of the equipment; they require evaluation, assembly and fitting; and they require ongoing support.”

#2: This lack of distinction is hurting complex rehab providers and consumers.

It’s easy for payors, referral sources, consumers and other stakeholders to contend that the separate benefit is largely about increasing funding for complex rehab. But the fact is that defining complex rehab as a slice of the larger DME pie ultimately hurts consumers. “When we see coverage changes or coverage limitations or when we see cutbacks, that’s eroding access to this technology,” Clayback says.

“From a supplier perspective, I think it’s well recognized that this segment isn’t a real attractive segment from a business perspective because it’s very service intensive, the profit margins are low, and the paperwork requirements are significant. From a pure business perspective, there’s a lot of challenges, which means there’s less companies that are remaining in this business. As those companies decrease, the patient access decreases. As those companies are forced to undergo ongoing reductions, they have to limit either product choice or limit services. They might not be able to continue to provide them under continued rate reductions.”

So, sure — providers’ businesses are being hurt. But ultimately, having fewer complex rehab businesses in existence will hurt the consumers who need the technology and all the expertise and service that goes along with it. Referral sources will also feel the frustration, if they have fewer qualified complex rehab professionals to call upon.

When it comes to the connection between funding problems and accessibility problems, Clayback explains, “I would say there’s a straight line — it’s not a dotted line, it’s not even a long line. If there is a reimbursement problem, that translates into an access problem. Or at least on the surface, immediately the access (question) should come up.

“When you look at complex rehab technology, we’ve done studies through NCART and there’s a variety of information that’s available. When you look at other segments in the market, the number of companies that provide complex rehab technology is very small, and that number is decreasing. So I can show you all kinds of financial reports and flow charts and all the steps that are involved, but this is a very difficult market to operate in, and I don’t think there’s any better evidence than to say, ‘Look at the few companies that are still operating in this business.’”

#3: This effort means no disrespect to DME.

Establishing a separate category for complex rehab isn’t a matter of having no respect for the existing DME benefit, but rather a matter of making sure complex rehab is defined and understood as accurately as possible.

“There definitely is a place for durable medical equipment,” Clayback says. “There’s definitely a place for respiratory equipment, so I think those are well-recognized product categories. What we’re saying is that when you start making decisions on coverage policy, payments, whatever, having these specialized (complex rehab) products lumped in with other categories presents some real access problems.”

#4: Complex rehab technology would finally be clearly defined.

Up until now, complex rehab technology has too often been defined in the eye of the beholder. Yes, Medicare made some inroads in separating consumer and complex rehab power chairs, but overall, it’s still an incomplete, overlapping and somewhat vague definition. For example, skin-protection and positioning wheelchair cushions were part of the recent Round 1 rebid as part of a category that Medicare calls Complex Rehabilitative Power Wheelchairs & Related Accessories — Group 2.

But with the new benefit category would come, finally, very specific definitions.

“We have clearly defined what complex rehab is,” Clayback says. “First, we started with more of a broad definition. We have crafted the definition so it isn’t just restricted to seating & mobility.”

In brief, Clayback says complex rehab would be defined as “an item that’s medically necessary, that’s configured to the individual and requires a combination of specific activities: evaluation, assembly, fitting, training, ongoing support.” The definition goes on to list the diagnoses of patients who typically use this type of equipment.

“Here’s the products, and here’s the people that use it,” Clayback says.

A more-detailed, two-page working definition includes what Clayback calls the “four Ps — the products that we’re talking about, the people who use it, the process that’s involved, and the professionals that are part of the delivery model.” The initial focus is on seating & mobility, plus “other adaptive equipment — standers, gait-trainers, other kinds of specialized equipment that fall under that definition.” But Clayback adds, “Speech-generating devices and other assistive communications devices would potentially fall under that. We’ve had some initial discussion with those groups, and they’re interested in this. They may become part of it or look to be involved down the road at some point.”

To identify the specific products that meet this new definition, Clayback says, “We’ve taken specific HCPCS codes — about 130 of them — that are either strictly complex rehab, or a significant part of that product code is complex rehab. One of the things we’d like to fix is for certain codes there’s an overlap: You have complex rehab products and standard mobility products. They both have a purpose and they both have a benefit, but for these specific HCPCS codes, you have to be an accredited complex rehab provider to provide them.”

#5: A seating & mobility client’s world should be made up of far more than four walls and a roof.

Once upon a time, the phrase “in the home” was used to distinguish durable medical equipment used in a Medicare beneficiary’s home from equipment used in a hospital or healthcare facility setting.

But that was a long time ago, and somewhere along the way, “in the home” morphed into a Centers for Medicare & Medicaid Services (CMS) restriction, one that perhaps inadvertently, but very effectively limited the definition of a Medicare beneficiary’s living spaces.

“We feel that, inappropriately, CMS interprets some of the language in the Social Security Act that says equipment is only covered in the home,” Clayback says. “We’re looking at eliminating that relative to complex rehab technology.

“If someone needs a power wheelchair, they should be able to access the necessary equipment, not just for their home needs, but also to get out into the community for their medical needs, social needs, educational, work and other needs. And really, our stated objective for this category is to improve and protect access for people with disabilities that need these products.”

Long the bane of complex rehab consumers, the in-the-home restriction might help stir consumer interest in the industry fight to establish a separate benefit category.

“The consumer is really the focus,” Clayback says, “and we’ve had some very productive discussions. I think this gives us the opportunity to have a stronger connection with consumer groups and have some frank discussions.” (Example: Paul Tobin, president of United Spinal Association, is a separate benefit category steering committee member.)

Discussions, Clayback adds, would concern how the status quo — complex rehab technology lumped in with DME, and dwindling numbers of complex rehab providers — is impacting consumers’ freedom of choice.

“If I’m a consumer…I want a company that’s got a good selection of products, that’s going to give me good customer service, and is going to be around if I need some sort of support,” he notes. “I think we all realize that for those companies to exist, the business environment has to be such that there’s appropriate coverage policies and payment rates.”

And speaking of payment rates: Next month, in part two of this column, we discuss three more reasons to support the separate benefit effort, including the role that funding will play, the need for new complex rehab technology provider standards, and the project’s various work groups, which are tackling this effort from several critical angles. Plus, we’ll share ways that you can get plugged in and help drive this meaningful effort.

The Social Security Determination

Wednesday, October 19th, 2011

Blogger Tim Moore explores how Social Security works with regard to those facing disability issues.

Social Security Disability (SSD) is awarded to individuals who file disability applications who can prove A) they have a severe, ongoing medical condition, and B) this this condition prevents them from being able to earn a living, either at a job they’ve done in the past, or at some form of other work for which they might possibly be suited based on their age, education, skills, and functional capacity.

Social Security makes all SSD determinations based on these core issues, closely examining claimants’ medical records and work histories in the process.

When you first file for SSD you will meet with a Social Security claims rep (called a CR) in a local social security office, who takes disability applications and then passes them on to the state disability determination services (DDS) agency (where decisions on claims are made by disability examiners).

At this initial interview you should supply the CR with, at the very least, a detailed contact list of any medical professionals or facilities at which you have received treatment for your condition. Be sure to include correct names, addresses, and phone numbers on your medical history–without this information, Social Security may not be able to get your records.

If you can get copies of your medical records before you meet with the CR, so much the better. Many, if not most physicians, are slow to comply with requests for records in disability matters, so providing a complete copy of this information at the time of filing can greatly speed up a decision in your case. Be sure to include records of any licensed medical professional from which you have sought help for your symptoms, not just physicians.

Psychologists, osteopaths, optometrists, and podiatrists, while not M.D.s, are all considered acceptable medical treatment sources by Social Security.

A chiropractor is not recognized as a medical expert by Social Security, but the results of any objective tests the chiropractor performs, such as X-rays, should be included in your case file, as a disability examiner may consider them in his or her decision.

In addition to your medical history, you must povide the CR with a complete, detailed work history of all of the jobs you’ve held in the last 15 years. Your work history is nearly as important as your medical history to the disability examiner who will decide your claim, because even those with obvious severe impairments (such as chronic pain, a debilitating injury, or even loss of limb) may be denied SSD if they cannot prove that their impairment prevents them from performing a past job or any other work at which they could earn the SGA amount.

SGA stands for substantial gainful activity, and if a disability examiner or judge decides that you could still earn the SGA amount you will be turned down for benefits. This, of course, is why it can be very important to have representation, particularly at the disability hearing level. A good disability attorney can address the issue of whether an individual’s condition sufficiently limits his or her ability engage in work activity that was previously performed, as well as address the issue of whether or not it is reasonable to believe that the claimant can switch to some form of other work that they have never done before.

Medicare Suffixes Found On Medicare Cards

Wednesday, October 19th, 2011

We often see Medicare numbers with suffixes that we don’t recognize. Here is an easy reference for just a situation.

Medicare Suffixes
Here’s what the letters behind the Medicare number mean:
*A = retired worker
B = wife of retired worker
B1 = husband of retired worker
B6 = divorced wife
B9 = divorced second wife
C = child of retired or deceased worker; numbers after
C denote order of children claiming benefit
D = widow
D1 = widower
D6 = surviving divorced wife
E = mother of a child of a deceased worker
E1 = divorced mother of a child of a deceased worker
F1 = aged dependent father
F2 = aged dependent mother
*HA = disabled worker
HB = wife of disabled worker
HC = child of disabled worker
*J1 = special “over 72” benefit, has A and B
K1 = wife of “over 72” benefit, has A and B
*M = has Part B Medicare only, no SSA benefit
*T = has A and B Medicare, no SSA benefit
W = disabled widow
WA = railroad retirement
*denotes the recipient’s own social security number.

Equipo Medico y Productos con 4 Localizaciones en Houston Texas

Wednesday, October 19th, 2011

Permítanme presentarme, mi nombre es Mayra Rivera. Una asistente de facturas con Active American. Estoy aquí para guiar a usted a través de lo que mi empresa hace y cómo le podemos ayudar. Somos una empresa de servicios, déjame explicarle, valoramos a nuestros clientes y trabajamos muy duro para el servicio de sus necesidades de movilidad. Entendemos que la movilidad de nuestros clientes es una parte importante de sus vidas como es una parte de nuestras vidas. Vamos a intentar todo lo posible para mantenerse en movimiento!

Nuestros servicios incluyen, pero no se limitan a:

· sillas de ruedas a medida de rehabilitación (eléctricas y manuales)
· equipo médico duradero (sillas de rueda, bastón, andador médico)
· equipo electronico de movilidad
· ascensor de paciente
· elevadores para sillas de ruedas, de vehiculos
· rampas
· equipo de oxigeno
· camas de hospital
· modificaciones en el hogar
· productos/equipo de alimentación
· productos urológicos

Esto solo es una portion de los servicio que podemos proporcionarle a usted. También estamos localizados en el área metropolitana de Houston, San Antonio y Dallas. Podremos proporcionarle equipo médicos que tal vez no sabía que existía; como medias de compresión, cuñas de espuma para cama, planteadas para el asiento de baño y muchas otras cosas de asistencia que podrían mejorar su calidad de vida. Es por eso que estamos aquí, nuestra missión es mantenerlos en movimiento con facilidad y conveniencia. Ya sea con la reparación de sus equipos, ayudándoles a adquirir nuevos equipos o mostrarle algo que podría ayudarles con sus actividades de la vida diaria. Estamos orgullosos de la labor que hacemos y por la gente que ayudamos cada día.

También ofrecemos ayuda a los clientes pediátricos. Ayudamos a niños que no pueden sostener su propio peso a hacerlo por primera vez. Igualmente ayudamos clientes que no pueden caminar la distancia suficiente para llegar a donde desean. La sonrisa en sus rostros es nuestra satisfacción y nos recuerda todos los días porque estamos aquí y porque hacemos lo que hacemos.

Si usted esta en necesidad o en busca de alguna de estas cosas, no dude en llamarnos. No se preocupe por la barrera de idioma ya que nuestras oficinas cuentan con personal bilingüe.

Patty Maldonado, coordinador de servicios- Stafford

Denise Ramos, asistente administrativa- Webster

Missy Garza, manejador de oficina- Lake Jackson

Rebeca Alanis, asistente de oficina-Lake Jackson

Mayra Rivera, asistente de facturas– Stafford

Con mucho gusto queremos ayudar a todos, esperamos oír de usted pronto

Active American Open House & Grand Opening- Lake Jackson

Tuesday, September 6th, 2011

Lake Jackson Texas- Active American Mobility and Medical Supply is pleased to announce the grand opening of our new location at 103 Circle Way in Lake Jackson. The event will be Friday, March 26th from 9am-5pm with free BBQ from 11-2.
Come check out the new state of the art showroom and see the latest products that we offer. There will of course be a sale so take advantage of the reduced prices offered this one day only.
While you are on site be sure to check out the new Accessible Bathroom display featuring a roll-in shower and other products and services provided by our new Home Access and Construction Division. Adam Horton, Division Manager, will be on hand to answer any questions you may have.
We will also have members of our Complex Rehab team available to answer questions and demonstrate complex rehab seating and wheelchairs.
Bring your loved ones and friends and come celebrate with us. We look forward to seeing you there!
For questions email pboardman@aamobility.com
Or call 979-297-3155

Medicare Suffixes Found On Medicare Cards

Friday, October 15th, 2010

by Patrick Boardman

We often see Medicare numbers with suffixes that we don’t recognize. Here is an easy reference for just a situation.

Medicare Suffixes
Here’s what the letters behind the Medicare number mean:
*A = retired worker
B = wife of retired worker
B1 = husband of retired worker
B6 = divorced wife
B9 = divorced second wife
C = child of retired or deceased worker; numbers after
C denote order of children claiming benefit
D = widow
D1 = widower
D6 = surviving divorced wife
E = mother of a child of a deceased worker
E1 = divorced mother of a child of a deceased worker
F1 = aged dependent father
F2 = aged dependent mother
*HA = disabled worker
HB = wife of disabled worker
HC = child of disabled worker
*J1 = special “over 72” benefit, has A and B
K1 = wife of “over 72” benefit, has A and B
*M = has Part B Medicare only, no SSA benefit
*T = has A and B Medicare, no SSA benefit
W = disabled widow
WA = railroad retirement
*denotes the recipient’s own social security number.

The Social Security Determination

Wednesday, October 13th, 2010

Blogger Tim Moore explores how Social Security works with regard to those facing disability issues.

Social Security Disability (SSD) is awarded to individuals who file disability applications who can prove A) they have a severe, ongoing medical condition, and B) this this condition prevents them from being able to earn a living, either at a job they’ve done in the past, or at some form of other work for which they might possibly be suited based on their age, education, skills, and functional capacity.

Social Security makes all SSD determinations based on these core issues, closely examining claimants’ medical records and work histories in the process.

When you first file for SSD you will meet with a Social Security claims rep (called a CR) in a local social security office, who takes disability applications and then passes them on to the state disability determination services (DDS) agency (where decisions on claims are made by disability examiners).

At this initial interview you should supply the CR with, at the very least, a detailed contact list of any medical professionals or facilities at which you have received treatment for your condition. Be sure to include correct names, addresses, and phone numbers on your medical history–without this information, Social Security may not be able to get your records.

If you can get copies of your medical records before you meet with the CR, so much the better. Many, if not most physicians, are slow to comply with requests for records in disability matters, so providing a complete copy of this information at the time of filing can greatly speed up a decision in your case. Be sure to include records of any licensed medical professional from which you have sought help for your symptoms, not just physicians.

Psychologists, osteopaths, optometrists, and podiatrists, while not M.D.s, are all considered acceptable medical treatment sources by Social Security.

A chiropractor is not recognized as a medical expert by Social Security, but the results of any objective tests the chiropractor performs, such as X-rays, should be included in your case file, as a disability examiner may consider them in his or her decision.

In addition to your medical history, you must povide the CR with a complete, detailed work history of all of the jobs you’ve held in the last 15 years. Your work history is nearly as important as your medical history to the disability examiner who will decide your claim, because even those with obvious severe impairments (such as chronic pain, a debilitating injury, or even loss of limb) may be denied SSD if they cannot prove that their impairment prevents them from performing a past job or any other work at which they could earn the SGA amount.

SGA stands for substantial gainful activity, and if a disability examiner or judge decides that you could still earn the SGA amount you will be turned down for benefits. This, of course, is why it can be very important to have representation, particularly at the disability hearing level. A good disability attorney can address the issue of whether an individual’s condition sufficiently limits his or her ability engage in work activity that was previously performed, as well as address the issue of whether or not it is reasonable to believe that the claimant can switch to some form of other work that they have never done before.

Why the ‘Separate Benefit’ Effort Should be Supported

Saturday, October 2nd, 2010

As Laurie Watanabe, editor of Mobility Management magazine, writes in her “Liberating Complex Rehab” column, an effort to secure a separate benefit for complex rehab technology seeks in essence to more accurately identify and define both the types of equipment used by severely involved seating & mobility clients, and the clinicians and suppliers conducting the evaluations, fittings, fabrications, adjustments, client training, and service/repair. This is part one of Watanabe’s column on why the separate benefit effort should be reversed.

There is danger in being labeled something you’re not — witness the 9.5-percent Medicare funding cut to the complex rehab power category after it was carved out of future Medicare competitive bidding programs.

#1: It’s time to stop comparing apples to oranges.

It’s an old, but entirely true argument: Complex rehab technology is different than DME.

“The big picture is that complex rehab technology is a small segment of the home medical equipment marketplace, and it is used by people who have in the majority of the cases very significant disabilities,” says Don Clayback, the new executive director of the National Coalition for Assistive and Rehab Technology.

“That’s why they need this kind of equipment.”

Complex rehab is currently considered merely a type or form of DME, which means its unique factors are often overlooked or not understood. Case in point: After intensive lobbying and education efforts from the industry, complex rehab power chairs and accessories were deemed inappropriate for Medicare competitive bidding and were thus carved out of future programs. Yet, when it was time to “pay for” a July 2008 postponement of the program, complex power was included in the 9.5-percent funding cut along with the rest of the product categories involved in the failed Round 1.

“What we see happening over the last few years,” Clayback says, “is because there’s really a lack of understanding of what’s involved in this from a payor perspective or a policy-maker perspective, there’s not the necessary appreciation of the complexity of the products, the service component of the delivery model and the costs that are incurred in that process. There’s not enough awareness of that, so consequently — whether it’s coverage changes or cutbacks or competitive bidding discussions — these products get included in there, and really they’re not appropriate based on those dimensions I mentioned.”

So if complex rehab technology is not DME, what is a good comparison? Possibly orthotics and prosthetics (O&P), Clayback says, “at least to communicate what we’re trying to accomplish.” He points out that O&P is “a separate category within the DME benefit. Orthotics and prosthetics are treated differently because they’re individual to the user of the equipment; they require evaluation, assembly and fitting; and they require ongoing support.”

#2: This lack of distinction is hurting complex rehab providers and consumers.

It’s easy for payors, referral sources, consumers and other stakeholders to contend that the separate benefit is largely about increasing funding for complex rehab. But the fact is that defining complex rehab as a slice of the larger DME pie ultimately hurts consumers. “When we see coverage changes or coverage limitations or when we see cutbacks, that’s eroding access to this technology,” Clayback says.

“From a supplier perspective, I think it’s well recognized that this segment isn’t a real attractive segment from a business perspective because it’s very service intensive, the profit margins are low, and the paperwork requirements are significant. From a pure business perspective, there’s a lot of challenges, which means there’s less companies that are remaining in this business. As those companies decrease, the patient access decreases. As those companies are forced to undergo ongoing reductions, they have to limit either product choice or limit services. They might not be able to continue to provide them under continued rate reductions.”

So, sure — providers’ businesses are being hurt. But ultimately, having fewer complex rehab businesses in existence will hurt the consumers who need the technology and all the expertise and service that goes along with it. Referral sources will also feel the frustration, if they have fewer qualified complex rehab professionals to call upon.

When it comes to the connection between funding problems and accessibility problems, Clayback explains, “I would say there’s a straight line — it’s not a dotted line, it’s not even a long line. If there is a reimbursement problem, that translates into an access problem. Or at least on the surface, immediately the access (question) should come up.

“When you look at complex rehab technology, we’ve done studies through NCART and there’s a variety of information that’s available. When you look at other segments in the market, the number of companies that provide complex rehab technology is very small, and that number is decreasing. So I can show you all kinds of financial reports and flow charts and all the steps that are involved, but this is a very difficult market to operate in, and I don’t think there’s any better evidence than to say, ‘Look at the few companies that are still operating in this business.’”

#3: This effort means no disrespect to DME.

Establishing a separate category for complex rehab isn’t a matter of having no respect for the existing DME benefit, but rather a matter of making sure complex rehab is defined and understood as accurately as possible.

“There definitely is a place for durable medical equipment,” Clayback says. “There’s definitely a place for respiratory equipment, so I think those are well-recognized product categories. What we’re saying is that when you start making decisions on coverage policy, payments, whatever, having these specialized (complex rehab) products lumped in with other categories presents some real access problems.”

#4: Complex rehab technology would finally be clearly defined.

Up until now, complex rehab technology has too often been defined in the eye of the beholder. Yes, Medicare made some inroads in separating consumer and complex rehab power chairs, but overall, it’s still an incomplete, overlapping and somewhat vague definition. For example, skin-protection and positioning wheelchair cushions were part of the recent Round 1 rebid as part of a category that Medicare calls Complex Rehabilitative Power Wheelchairs & Related Accessories — Group 2.

But with the new benefit category would come, finally, very specific definitions.

“We have clearly defined what complex rehab is,” Clayback says. “First, we started with more of a broad definition. We have crafted the definition so it isn’t just restricted to seating & mobility.”

In brief, Clayback says complex rehab would be defined as “an item that’s medically necessary, that’s configured to the individual and requires a combination of specific activities: evaluation, assembly, fitting, training, ongoing support.” The definition goes on to list the diagnoses of patients who typically use this type of equipment.

“Here’s the products, and here’s the people that use it,” Clayback says.

A more-detailed, two-page working definition includes what Clayback calls the “four Ps — the products that we’re talking about, the people who use it, the process that’s involved, and the professionals that are part of the delivery model.” The initial focus is on seating & mobility, plus “other adaptive equipment — standers, gait-trainers, other kinds of specialized equipment that fall under that definition.” But Clayback adds, “Speech-generating devices and other assistive communications devices would potentially fall under that. We’ve had some initial discussion with those groups, and they’re interested in this. They may become part of it or look to be involved down the road at some point.”

To identify the specific products that meet this new definition, Clayback says, “We’ve taken specific HCPCS codes — about 130 of them — that are either strictly complex rehab, or a significant part of that product code is complex rehab. One of the things we’d like to fix is for certain codes there’s an overlap: You have complex rehab products and standard mobility products. They both have a purpose and they both have a benefit, but for these specific HCPCS codes, you have to be an accredited complex rehab provider to provide them.”

#5: A seating & mobility client’s world should be made up of far more than four walls and a roof.

Once upon a time, the phrase “in the home” was used to distinguish durable medical equipment used in a Medicare beneficiary’s home from equipment used in a hospital or healthcare facility setting.

But that was a long time ago, and somewhere along the way, “in the home” morphed into a Centers for Medicare & Medicaid Services (CMS) restriction, one that perhaps inadvertently, but very effectively limited the definition of a Medicare beneficiary’s living spaces.

“We feel that, inappropriately, CMS interprets some of the language in the Social Security Act that says equipment is only covered in the home,” Clayback says. “We’re looking at eliminating that relative to complex rehab technology.

“If someone needs a power wheelchair, they should be able to access the necessary equipment, not just for their home needs, but also to get out into the community for their medical needs, social needs, educational, work and other needs. And really, our stated objective for this category is to improve and protect access for people with disabilities that need these products.”

Long the bane of complex rehab consumers, the in-the-home restriction might help stir consumer interest in the industry fight to establish a separate benefit category.

“The consumer is really the focus,” Clayback says, “and we’ve had some very productive discussions. I think this gives us the opportunity to have a stronger connection with consumer groups and have some frank discussions.” (Example: Paul Tobin, president of United Spinal Association, is a separate benefit category steering committee member.)

Discussions, Clayback adds, would concern how the status quo — complex rehab technology lumped in with DME, and dwindling numbers of complex rehab providers — is impacting consumers’ freedom of choice.

“If I’m a consumer…I want a company that’s got a good selection of products, that’s going to give me good customer service, and is going to be around if I need some sort of support,” he notes. “I think we all realize that for those companies to exist, the business environment has to be such that there’s appropriate coverage policies and payment rates.”

And speaking of payment rates: Next month, in part two of this column, we discuss three more reasons to support the separate benefit effort, including the role that funding will play, the need for new complex rehab technology provider standards, and the project’s various work groups, which are tackling this effort from several critical angles. Plus, we’ll share ways that you can get plugged in and help drive this meaningful effort.

Power Wheelchairs and Power Operated Vehicles Documentation Requirements

Friday, October 1st, 2010

Posted by Patrick Boardman

September 2010

Dear Physician,

In order for Medicare to provide reimbursement for a power wheelchair (PWC) or power operated vehicle (POV) (scooter), there are several statutory requirements that must be met:
1. There must be an in-person visit with a physician specifically addressing the patient»s mobility needs.
2. There must be a history and physical examination by the physician or other medical professional (see below) focusing on an assessment of the patient»s mobility limitation and needs. The results of this evaluation must be recorded in the patient»s medical record.
3. A prescription must be written AFTER the in-person visit has occurred and the medical evaluation is completed. This prescription has seven required elements (see below).
4. The prescription and medical records documenting the in-person visit and evaluation must be sent to the equipment supplier within 45 days after the completion of the evaluation.
The in-person visit and mobility evaluation together are often referred to as the ≈face-to-face examinationΔ.
The complete history and physical examination typically includes:
• History of the present condition(s) and past medical history that are relevant to the patient»s mobility needs in the home:
• Symptoms that limit ambulation
• Diagnoses that are responsible for these symptoms
• Medications or other treatment for these symptoms
• Progression of ambulation difficulty over time
• Other diagnoses that may relate to ambulatory problems
• How far the patient can walk without stopping and with what assistive device, such as a cane or walker
• Pace of ambulation
• History of falls, including frequency, circumstances leading to falls, and why a walker isn»t sufficient
• What ambulatory assistance (cane, walker, wheelchair) is currently used and why it isn»t sufficient
• What has changed to now require use of a power mobility device
• Ability to use a manual wheelchair
• Reasons why a power operated vehicle (scooter) would not be sufficient for this patient»s needs in the home
• Description of the home setting and the ability to perform activities of daily living in the home
• Physical examination that is relevant to the patient»s mobility needs
• Weight and height
• Cardiopulmonary examination
• Musculoskeletal examination
Also:

Arm and leg strength and range of motion
Neurological examination
Gait
Balance and coordination

If the patient is capable of walking, the report should include documented observation of ambulation (with use of a cane or walker, if appropriate)
Examples of vague or subjective descriptions of the patient’s mobility limitations include:

• upper extremity weakness
• poor endurance
• gait instability
• weakness
• abnormality of gait
• difficulty walking
• SOB on exertion
• pain
• fatigue
• deconditioned

These types of statements are insufficient and do not objectively address the mobility limitation or provide a clear picture of the patient’s mobility deficits. Objective measurements should be provided.

The evaluation should be tailored to the individual patient»s conditions. The history should paint a picture of your patient»s functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the patient»s ambulatory difficulty or impact on the patient»s ambulatory ability.

It is important to keep in mind that because of the way that the Social Security Act defines durable medical equipment, a power mobility device is covered by Medicare only if the beneficiary has a mobility limitation that significantly impairs his/her ability to perform activities of daily living within the home. If the wheelchair/POV is needed in the home, the beneficiary may also use it outside the home. However, in your evaluation you must clearly distinguish your patient»s mobility needs within the home from their needs outside the home.
You may elect to refer the patient to another medical professional, such as a physical
therapist or occupational therapist, to perform part of the evaluation √ as long as that individual has no financial relationship with the wheelchair supplier. However, you do have to personally see the patient before or after the PT/OT evaluation. You must review the report, indicate your agreement in writing on the report, and sign and date the report. If you do not see the patient after the PT/OT evaluation, the date that you sign the report is considered to be the date of completion of the face-to-face examination.
You should record the visit and mobility evaluation in your usual medical record-keeping format. Many suppliers provide forms for you to complete. Suppliers often try to create the impression that these documents are a sufficient record of the in-person visit and medical evaluation. Based upon our auditing experience, most of them are not. That is because they typically contain check-off boxes or space for only brief answers and thus do not provide enough detailed information about the patient»s ambulatory abilities and limitations to allow the Medicare contractor to determine if coverage criteria have been met . Forms such as those developed by the Texas or Florida Academy of Family Physicians are designed to gather selected bits of information and are almost always insufficient. What is required is a thorough narrative description of your patient»s current condition, past history, and pertinent physical examination that clearly describes their mobility needs in the home and why a cane, walker, or optimally configured manual wheelchair is not sufficient to meet those needs.
You may write a prescription for a power mobility device ONLY after the visit and examination are complete. This prescription must contain the following seven elements:
1)Beneficiary»s name
2) Description of the item that is ordered. This may be general √ e.g., ≈power operated vehicleΔ, ≈power wheelchairΔ, or ≈power mobility deviceΔ√ or may be more specific.
3) Date of completion of the face-to-face examination
4) Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
5) Length of need
6) Physician»s signature
7)Date of physician signature

You must forward a copy of the face-to-face evaluation and your seven-element prescription to the supplier within 45 days from the completion of the face-to-face mobility exam. You should also include copies of previous notes, consultations with other physicians, and reports of pertinent laboratory, x-ray, or other diagnostic tests if they will help to document the severity of your patient»s ambulatory problems.
After the supplier receives your order and the face-to-face information, they will prepare a detailed product description that describes the item(s) being provided including all options and accessories. You should review it and, if you agree with what is being provided, sign, date and return it to the supplier. If you do not agree with any part of the detailed product description, you should contact the supplier to clarify what you want the beneficiary to receive.
This information is not intended to serve as a substitute for the complete DME MAC
local coverage determination on Power Mobility Devices. It is only a synopsis detailing the highlights of documentation. Refer to the complete LCD and Policy Article on the CMS Web site at www.cms.hhs.gov/mcd/overview.asp for additional information.
Medicare does provide you additional reimbursement (HCPCS code G0372) to recognize the additional time and effort that are required to provide this documentation to the supplier. This code is payable in addition to the reimbursement for your E&M visit code.
Your participation in this process and cooperation with the supplier will allow your patient to receive the most appropriate type of mobility equipment. We appreciate all your efforts in providing quality services to your Medicare patients.

Sincerely,
Paul J. Hughes, M.D.
Medical Director, DME MAC, Jurisdiction A
Robert D. Hoover, Jr., MD, MPH, FACP Medical Director, DME MAC, Jurisdiction C
Adrian M. Oleck, M.D.
Medical Director, DME MAC, Jurisdiction B
Richard W. Whitten, MD, MBA, FACP
Medical Director, DME MAC, Jurisdiction D

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