Posts Tagged ‘Medicare’

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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Congress Must Pass Legislation To Restore Medicare 9.5 Percent Cut To Complex Rehab Products

Wednesday, October 19th, 2011

Background
The Medicare Modernization Act of 2003 established a competitive bidding program for durable medical equipment (DME) that included complex power wheelchairs and accessories in the bidding list. In 2008 Congress saw this was a problem and passed MIPPA to exempt these products from inclusion in competitive bidding recognizing these products were not appropriate for bidding because of their complexity and individualized nature. MIPPA also included legislation that delayed the implementation of the DME competitive bidding program for 18 months. To pay for the delay, the DME categories selected for competitive bidding were subjected to a 9.5 percent reduction in Medicare reimbursement. Unfortunately, this reduction was also applied to the “exempted” complex rehab products and these products cannot withstand such a reduction. This reduction to complex rehab must be restored.

Basis for Restoration
The reasons that this reduction must be restored as soon as possible include:

•As part of the MIPPA legislation, Congress exempted complex rehab power wheelchairs from competitive bidding because it recognized complex rehab products are different from traditional DME in that they are individually customized to meet the medical and functional needs of people with disabilities. Since Congress exempted these products from competitive bidding, these items should also have been exempted from the 9.5 percent reduction that was applied to traditional DME products as part of MIPPA.
•Complex power wheelchairs are a very small Medicare product category and account for less than 10% of the overall Medicare mobility benefit expenditures. For this limited product group, the most generous savings estimates show less than $10 million annually. While not a minor dollar amount, it is insignificant when viewed in light of the negative consequences the cut has for those individuals with complex disabilities.
•Beneficiaries who have in the past received appropriately configured wheelchairs will be unable to receive comparable products when their mobility systems need to be replaced. This will affect their levels of independence, their mobility, and their ability to function optimally in their environment. Likewise, beneficiaries needing new power wheelchairs may be unable to receive the most appropriate technology. This will lead to more medical complications for complex rehab consumers which will ultimately increase health care costs elsewhere in the Medicare program.
•Access to necessary services and repairs will be reduced. There will be limited availability of offsite assessments and evaluations in addition to delays in accessing chairs and receiving necessary repairs. Reductions in repair services will result.
•Congress did not realize that for complex rehab payments this 9.5 percent reduction would not be limited to just Medicare beneficiaries. It has also been adopted by state Medicaid programs and other third party payers to further reduce available funding of these products. This has further compromised the quality of products and services available across the country.
•Studies indicate that complex rehab technology companies that provide these products and services have pre‐tax profits of less than 4 percent, making them unable to sustain a 9.5 percent reduction without significantly reducing services and limiting the types of products they are able to provide.

Position Paper from NCART 2009

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

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.

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