Posts Tagged ‘Documentation’

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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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

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