Posts Tagged ‘CMS’

Medicare Clarifies PMD (Power Mobility Device) Documentation Requirments for Power Wheelchairs and Scooters

Wednesday, October 19th, 2011

By Patrick Boardman

Active American Mobility and Medical Supply is a Complex Rehab company in Houston and San Antonio Texas.

CMS released a clarification letter with respect to PMD documentation requirments. The letter came out on September 10th.

The following is a copy of that September 10th letter:

Power Wheelchairs and Power Operated Vehicles Documentation Requirements
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


Arm and leg strength and range of motion
Neurological examination
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 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.

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

Urgent Reminder: Physicians Must Enroll In Medicare PECOS System

Wednesday, October 19th, 2011

As if physicians didn’t have enough to worry about with the perennial cliffhanger of Medicare pay cuts — this year’s 21% reduction is only on hold — many of them were at risk of not being paid at all starting on Jan. 1.

That’s why the Centers for Medicare & Medicaid Services did the right thing by postponing a deadline for physicians to make sure they are signed up properly with Medicare’s newest enrollment system. Doctors who order Medicare services or refer patients for such services now have until April 5 to determine whether they are up to date in the program’s Provider, Enrollment, Chain and Ownership System, known as PECOS. CMS had warned that it would stop paying claims at the beginning of the year for those who had not complied with the new enrollment policy.
■See related content
■Topic: Medicare
It’s not enough that practices have their own records in order. If a doctor lists a referring physician on a claim for a particular patient and that referring physician is not in PECOS, the billing doctor will not get paid.

If a physician has never heard of PECOS, there’s a good chance that he or she will need to contact the appropriate Medicare contractor or visit the PECOS Web site to re-enroll. The American Medical Association and dozens of other physician organizations who argued for the delay estimated that as many as 200,000 doctors fit into that category — about 30% of those to whom the directive applies. Many of these physicians enrolled in Medicare before 2003, when CMS started using the new system.

CMS says the re-enrollment process is simple, but the penalty for not updating the records with Medicare can be severe.

Starting in October 2009, Medicare contractors began including informational edits on claims listing physicians who were not properly enrolled in PECOS, letting the billing physicians know that they had until the end of 2009 to fix the issue or risk seeing their Medicare cash flow dry up.

But those who did not see or did not understand the informational notes on their claims were left in the dark about what to do. And physicians hardly can be blamed for overlooking Medicare’s own housekeeping issues with so much at stake in the national debate over health system reform and the threatened draconian cut to physician pay.

Quick action by the AMA and other members of organized medicine prevented a potential New Year’s disaster for many billing Medicare for services or listing referring physicians on their claims. But while an additional three months might seem like plenty of time for one doctor to file a paper Medicare application or use Internet-based PECOS enrollment, that might be a tight timeline for a larger practice that needs to sign up multiple doctors. The AMA already has asked CMS for additional time to comply and will continue to monitor the situation closely.

With a few exceptions, doctors who are not signed up with PECOS will need to re-enroll with Medicare. That includes pediatricians, dentists and others who may see few Medicare beneficiaries. Those who see or refer patients through the Dept. of Veterans Affairs, the Public Health Service or Tricare also will need to comply.

CMS is recommending that all physicians ensure that their enrollments are up to date and compliant by contacting their Medicare contractors or viewing their records online. A current record is one that is in the PECOS database with all the correct information, including National Provider Identifier, or NPI.

Physicians also can obtain more Medicare enrollment information on the AMA’s regulatory advocacy Web site (

With some advance planning — and if Medicare contractors and CMS meet their own responsibilities — doctors can ensure that the government keeps paying them, on time, for all the work they do for their patients.