Posts Tagged ‘ADMC’

Medicare Power Mobility Documentation Requirements

Wednesday, October 19th, 2011

July 10, 2008
Power Mobility Documentation Requirements

A review of power mobility claims and ADMC requests submitted to Jurisdiction C shows continued uncertainty regarding the various assessment and evaluation documentation requirements. The following article reviews this information and includes a reference chart indicating the assessment and exam requirements for the various levels of power mobility.

Face-to-Face Exam

What is It?

The face-to-face examination is a statutory requirement for all power mobility devices (PMD). This exam consists of two separate elements, an in-person visit to the physician for the purpose of requesting a PMD, and a comprehensive medical examination.

Who Can Perform It?

The treating physician must conduct the in-person visit. The comprehensive medical evaluation may be performed by the physician or may be referred to a licensed/certified medical professional (LCMP), such as a physical therapist or occupational therapist, who has experience and training in mobility evaluations to perform part of the exam. If the treating physician has referred the medical examination to a LCMP, the physician must review the findings after receiving the LCMP’s report. In addition the physician must document their acceptance of this report in writing and sign and date the entry.

REMINDER: If the report of an LCMP examination is to be considered as part of the face-to-face examination, there must be a signed and dated attestation by the supplier that the LCMP has no financial relationship with the supplier.

How Should the Findings be Reported?

The in-person element of the face-to-face exam should be documented in a detailed narrative note in the physician’s chart in the format that they use for other entries and clearly indicate that a major reason for the visit was a mobility examination. The comprehensive medical examination may be documented either:

In the physician’s narrative record, if they performed the entire exam; or,

By including the report of the LCMP exam in the office record if the exam was referred.

A supplier generated form must not be used to document either the treating physician’s or LCMP’s exam since a supplier generated form is not a considered to be a part of the medical record.

REMINDER: The supplier must receive a written report of the face-to-face exam within 45 days after its completion and prior to delivery of the wheelchair.

Specialty Exam

What is It?

The specialty evaluation is a written report providing a detailed explanation of why a particular power wheelchair base and each specific option or accessory is needed to address the patient’s mobility limitation.

A specialty exam is a mandatory requirement prior to dispensing a Group 2 Single Power Option or Multiple Options PWC, any Group 3, 4 or 5 PWC, or a push-rim activated power assist device.

Who Can Perform It?

The specialty exam must be performed by a licensed/certified medical professional, such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations. The person performing this exam may, but is not required to be, a RESNA-certified ATP.

REMINDER: The PT, OT, or physician performing the specialty exam may have no financial relationship with the supplier.

How Should the Findings be Reported?

The policy does not prescribe a specific format for reporting the specialty exam findings. However, the report should be in the office or facility’s usual medical record form; it should not be on a supplier-generated form.

Home Assessment

What Is It?

All levels of PMD require that an onsite evaluation of the patient’s home be performed prior to or at the time of delivery. The person conducting this assessment should verify and document, in a written report, that the patient’s typical environment supports the use of a PMD.

Who Can Perform It?

The home assessment can be performed by the supplier (or supplier’s employee) or a practitioner (physician, physician’s employee or LCMP, etc.).

How Should the Findings be Reported?

The policy does not specify a particular format or form to use. The policy, however, does state that the assessments and measurements should include physical layout of the home, doorway width, doorway thresholds and surfaces the device will have to move over.

ATS/ATP In-person Appraisal

What Is It?

As of April 1, 2008, suppliers providing certain wheelchairs as described in the PMD LCD must employ a RESNA credentialed professional and this person must have direct in-person involvement in the wheelchair selection process. For an in-depth review of this requirement, please refer to the recently published article, Power Mobility Devices, FAQ – ATS/ATP Requirements.

Who Can Perform It?

This process must be performed by either a RESNA-certified Assistive Technology Supplier (ATS) or Assistive Technology Practitioner (ATP) who specializes in wheelchairs and is employed by the supplier.

NOTE: The requirement for the supplier to employ a RESNA-certified professional and for this person to have direct, in-person involvement in the wheelchair selection process is not waived if the specialty exam is performed by an ATP. The person performing the specialty exam cannot work for the supplier and the person involved in the ATS/ATP in-person appraisal must have a financial relationship with the supplier. Therefore, one individual cannot meet both requirements.

How Should the Findings be Reported?

There must be evidence in the supplier’s file of direct in-person interaction with the patient by the ATS/ATP in the wheelchair selection process. The documentation must be complete and detailed enough so a third party would be able to understand the nature of the ATS/ATP involvement and to show that the standard was met. Just “signing off” on a form completed by another individual would not adequately document direct, in-person involvement. Also, merely signing a statement such as, “I am a RESNA-certified professional specializing in wheelchairs and had direct, in-person involvement in the wheelchair selection for this patient” does not sufficiently verify that this policy requirement was met. Finally, a home assessment completed by a supplier-employed ATS/ATP would not meet the requirement unless the documentation showed how the ATS/ATP applied the assessments and measurements to the wheelchair selection process.

REFERENCE CHART: PMD EVALUATION/ASSESSMENT REQUIREMENTS

PMD Group HCPCS Code Range Face-to-Face Exam Specialty Exam Home Evaluation ATS/ATP In-person Appraisal

Group 1 POV K0800-K0802 Yes No Yes No

Group 2 POV K0806-K0808 Yes No Yes No

Group 1 PWC K0813-K0816 Yes No Yes No

Group 2 PWC – NPO K0820-K0829 Yes No Yes No

Group 2 PWC – SPO K0835-K0840 Yes Yes Yes Yes

Group 2 PWC – MPO K0841-K0843 Yes Yes Yes Yes

Group 3 PWC – NPO K0848-K0855 Yes Yes Yes Yes

Group 3 PWC – SPO K0856-K0860 Yes Yes Yes Yes

Group 3 PWC – MPO K0861-K0864 Yes Yes Yes Yes

Group 4 PWC K0868-K0886 Yes Yes Yes Yes

Group 5 PWC K0890-K0891 Yes Yes Yes Yes

Abbreviation Key PMD = Power Mobility Device

POV = Power Operated

Vehicle

PWC = Power Wheelchair MPO = Multiple Power Options

NPO = No Power Options

SPO = Single Power Option

Refer to the Power Mobility Devices LCD for additional information on coverage and documentation requirements.

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Medicare ADMC: Untangling the Confusion about this Medicare Service for Mobility Products

Wednesday, October 19th, 2011

By Patrick Boardman
281-495-4400

ADMC: Advanced Determination of Medicare Coverage

There seems to be a lot of confusion out there about ADMC. At Active American we utilize this voluntary service virtually every day. This program offers a great way to hedge your bets if you are unsure about getting paid for a Medicare item. In the Mobility arena these items are Ultra lightweight Wheelchairs (K0005 & K0009) and also Group II power wheelchairs with at least one power function, and Group III power wheelchairs. In our day to day operations, we often run into situations where chart notes or documentation is marginal. In this situation our best option is to utilize the ADMC program.

A few common scenarios where ADMC might be utilized:
1. Same or similar coverage identified by IVR system showing an existing chair on file within 5 years.
2. Limited or marginal documentation
3. Diagnosis or health condition that histroically has resulted in a denials for the type of product being recommended for the patient.

Now there are a few points to remember when submitting an ADMC request.

1. Utilize the checklist provided by Medicare: I cannot stress this enough.
2. Ensure that your dates for F2F, WO and DPD are accurate. For example, if your WO is dated prior to the date of F2F completion this will result in an obvious negative ADMC decision.
3. Ensure that you can attest and prove that an ATP was present and participated in the evaluation.
4. Be aware that if you omit just one document or one thing is out of order, Medicare will render a negative decision. If this happens you have only one more chance to resubmit. If you get a second negative decision you may not resubmit for 6 months.
5. The ADMC process takes about 30 days so factor this into your eval to delivery time frame.

With proper and correct documentation, using ADMC can be a great way to make sure that you stay in business!

Here are some helpful links with respect to ADMC: (This example and links are jurisdiction D so be sure to use the appropriate forms for your jurisdiction.

ADMC Cover Sheet- https://www.noridianmedicare.com/dme/forms/docs/ADMC_Request_Cover_Sheet.pdf

ADMC Request Form-
https://www.noridianmedicare.com/dme/forms/docs/ADMC_Request_form.pdf

List of HCPC Codes Eligible for ADMC-

https://www.noridianmedicare.com/dme/coverage/docs/admc_hcpcs_list.pdf

ADMC LCD-

ADMC requests may either be mailed or faxed to:

Noridian Administrative Services LLC
DME Jurisdiction D Medical Review
PO Box 6747
Fargo ND 58108-6747

ADMC Fax #: 877-662-8445

If you have questions please feel free to give us a call.

Patrick Boardman, Dir of Business Development
Active American Mobility and Medical Supply
281-495-4400

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