Transcript Mobility Assist Equipment CMS Decision Memo
Mobility Assist Equipment A to Z It is not JUST About POWER
Reviewed and updated 9/26/2011 Jackson MS 10/4/2011
Peggy Walker, RN US Rehab/VGM 803-754-2090--800-401-3643 803 754 2091 [email protected]
V fax 877 907 3862
Mobility Assist Equipment
effective5/5/05-implementation 7/7/05
THE DECISION THE SAGA BEGINS
CMS determined that Beneficiaries might need help to complete adls. {DUH}
If – they have a personal mobility deficit sufficient to impair their participation in mobility related ADLS
Mobility related ADLS such as toileting, dressing, feeding , grooming & bathing –
IN :”customary locations in the home” OKOKOK - What does this mean?
BE CAREFUL about assisted living and needing to go to dining room – not written anywhere and on reviews money is being recouped meals in apt?
– is this where they usually go for all meals? Can they prepare
Modification of the Medicare National Coverage Determination Manual
effective date 5/5/05 implementation 7/5/05
Replace coverage indications on: ALL MAE CANES (all types); Walkers; crutches; geri chairs; power & manual w/s; POVs ; special size w/cs Rolling chairs will maintain the coverage limitations on caster size (geri)
Determination of type of deficit
Use of an algorithm process (ALL MAE) Assessment of individual needs ****Functional needs**** as related to need to participate in mobility related activities of daily living Such as: personal hygiene; feeding; dressing etc.
Remember these are not diagnosis driven but ****functional needs**** driven.
Who is qualified to do the patient evaluation & other statements addressed
CMS decision states this is beyond the scope of the NCD (National Coverage Decision) Documentation issues are best addressed in an initiative separate from this NCD due to the complexity of the issues.
Outside the home: the primary purpose of DME is to assist individuals in the home and “our regulations require that this equipment be appropriate for use in the home” Assessment will be a step wise from canes & walkers through manual & power wheelchairs.
Other issues addressed
Local contractors would determine need for multiple MAEs concurrently.
Non-compliance would also be a reason for denial The environment must be assessed (verbally; via phone or at delivery for Manual –physical evaluation for Power Canes, crutches, walkers fall along a continuum of technology so any discussion that did not include them would be incomplete
Clinical Algorithm What does this mean?
CMS has developed a “decision tree” to be followed in deciding the appropriate equipment for the beneficiaries individual needs as related to functional ADLs within the home This will make it easier for some areas but most Rehab providers have already developed this type of process & work well with referral sources BE ALERT to all requirements –use documentation check off sheets available through your jurisdictions (D & Cs are comprehensive check offs)
Clinical Criteria
NOTE: Date stamp documentation from physician effective {not accepting fax date at top of page due to multiple faxing} (power) 6/5/06
Physician/ordering practitioner establishes that there is a mobility limitation – pt needs assistance of some type of MAE- willingness to use! { A therapist evaluation DOES NOT negate need for F2F by physician} Other conditions – cognition; judgment; vision – completing adls within a reasonable time frame NOTE _ when therapist involved it is a combination of both that completes the F2F and 7 element order date would be date of “completion of” face to face – when physician reviews and signs off on clinical evaluation.
Other Limitations Exist
If these exist can other provisions be made for use of equipment?
A – Caregiver (family member) available & who is willing and able to assist the beneficiary using the w/c B - Compliance or non-compliance with use of device (pt refuses to use can be grounds for denial.
1.
Safety Issues
Has the beneficiary/caregiver demonstrated the capability & ***willingness*** to operate the MAE safely?
a.
b.
c.
Risk to beneficiary and others must be addressed in safe use of item History of unsafe behavior?
Was there an actual trial of the equipment or follow up survey to make sure item provided was appropriate & patient is able to use?
WOPD/Detailed Written Order
A supplier must have a verbal, faxed, or original order in their records before they provide any item of durable medical equipment, prosthetics, orthotics and supplies to a beneficiary.
WOPD/ Detailed written order must contain: Patient’s name; Description of the item (the description can be either a narrative or a brand name/model number) and the length of need.; If order is for accessories/supplies that will be provided on a periodic basis, it must include appropriate information on the quantity used, frequency of change or use, and length of need.; If order is for a drug, it must specify the name of the drug, concentration (if applicable), dosage, frequency of administration, and duration of infusion (if applicable). ; Patient’s diagnosis (policy applicable).; Expected start date of the order; The physician’s signature and date.
***POWER (any type) must also include the actual date of F2F*** {7 element order}
Documentation
For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type & quantity of items ordered & for the frequency of use or replacement (if applicable). ---- However, neither a physician’s order nor a CMN nor a DIF nor a physician attestation statement by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. ----”
Clinical Review Judgment MM 6954 Effective 4/23/2010
1. The synthesis of all submitted medial record information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient, and 2. The application of this clinical picture to the review criteria to determine whether the clinical requirements in the relevant policy have been met.
NOTE – Clinical review judgment does NOT replace poor or inadequate medical record documentation, nor is it a process that review contractors can use to override, supersede or disregard a policy requirement (policies include laws, regulations, Centers for Medicare & Medicaid (CMS) rulings, manual instructions, policy articles, national coverage decisions, and local coverage determinations.).
Cane - Walkers
Can the functional deficit be resolved with use of a cane or walker?
These should be **appropriately** fitted to the pt. for this evaluation. Can the patient “safely” use the cane or walker to complete MRADLs? Gait instability
Environment Assessment
Can the beneficiary’s typical environment support the use of w/c including scooters/POVs?
Physical lay out; surfaces; & obstacles which would prevent use of the equipment in the home. Remember “in the home” is still there – If you need a bariatric chair for the bariatric patient will it fit in the home?
Will the patient be able to move around in the home with what ever item is provided & complete MRADLs?
Is there adequate access (ramps)
Manual vs Power Upper extremity functions
What are limitations of strength, endurance, range of motion, coordination or is there absence of or deformity of one or both UEs/ Upper extremity function would determine level of manual w/c ie:lgt wgt vs standard Is the surface area clear and are surfaces OK for manual w/c propulsion (rugs, clutter etc.) Can pt. “safely” use the manual w/c ***needs to be noted*** **If unable & there is a caregiver who is available, willing & able to provide assistance a manual w/c may be appropriate** DOCUMENTATION – is the key
Manual Wheelchairs
KX required on base and accessories 5/1/07 KE {1/1/09} required accessories that could be billed on round 1 competitive bid pmds.
Categories: Capped Rental:K0001, K0002, K0003, K0004, K0006, K0007,E1031, E1038, E1039 Inexpensive Routinely purchased: K0005;E1161 E1231;E1233;E1234 (Rent /Purchase) {*ADMC} Other Wheelchair Base: K0009 {ADMC}* * Can go to ADMC but not required.
MWCs codes to be revised
will be done by dmepdac no updates on this KE modifier required 1/1/09 for any accessory that could’ve been billed on a competitive bid pwc.
The practitioner caring for the patient orders the equipment.
Practitioner can be : physician, licensed nurse practitioner, clinical nurse specialist or physicians assistant.
On a post pay audit the reviewer would expect to see: 1. Copy of order (if verbal will need a confirmation of verbal/phone order) 2. Detailed written order which is to be completed by supplier for physician/practitioner to review, sign & date (prior to bill on manual).
3. Beneficiary Authorization 4. Proof of delivery 5. Medical records which documents need
Bases (K0001 – K0002)
Although a F2F order is not required there still must be an ordering practitioner involved for ANY DME.
Standard manual K0001 would need diagnosis relating to inability to ambulate or use a cane or walker (basic information stating unable to use & why) Hemi – height K0002 would need the basic info as well as why a lower seat to floor height is required (for foot propulsion or stand/pivot transfers) Height of patient – measurement of lower extremities need to be included
K0003 – K0004
K0003 (light weight manual) would need the basic info plus documentation stating why a K0001 would not meet needs and that the patient is able to self propel in base being provided.
K0004 (high strength light weight) basic info plus why a K0001 – through K0003 would not meet needs. ( height/weight/ measurements ) what is available on the K0004 base that is not available on lower level base. Patient activity level +(
in chair >2hours/day)
Functional needs – what exactly do they need to get from point A to point B and complete their daily activities?
K0005 (can go to ADMC)
K0005 – Basic information plus – what is available on a K0005 that is not available on a K0004. *** MUST be specific*** MAXIMAL (front to back) axle adjustability and why needed*** / or rigid base Individual consideration only -- (can go to ADMC) ***Past use of same/similar equipment*** ADLs - specific to the individual and not broad or vague/ patient must be able to self propel in base being provided. {what do they do in this base that they can not accomplish in a K-4} Not just basic axle adjustability which some K0004s do have and not “just” a few pounds difference in weight WHY do they “NEED” this base to complete MRADLs NEED vs WANT
K0006 – K0007- K0009
K0006 – Heavy duty base – basic information plus weight or diagnosis of acute spasticity Weight must be greater than 250 pounds weight can go in narrative field K0007 extra heavy duty – weight greater than 300 pounds plus basic info K0009 – Individual consideration – name, make, model and MSRP of base being provided and why a lower level base would not meet needs. Basic mobility information required as well
Manual tilt (E1161 – E1231-E1234) Can go to ADMC Manual tilt in space – E1161 (adult) E1231 –E1234 (pediatric) – basic info for mobility first – PT/OT not required but best to do one (power tilt for manual tilt in space (K0108)
Why a standard base with reclining back will not meet needs – past history of same/similar equipment – ADLS – caregiver assist -- being reviewed individually – F2F not required but must show ordering practitioners’ involvement & PT/OT evaluation important. Transporter Chairs {NO ADMC available} E1038 /E1039(HD)– transporter chair or E1031 (roll about chair) To be provided “in lieu of” a standard w/c so need basic information relating to need for a w/c for mobility and not just needed for “outside the home”
POVs-ASSESSMENT
Basically rules are the same Does pt. have strength & postural stability to operate?
Is there adequate access (space) “in the home” Does the pt. have the ability to safely operate the POV F2F & Home eval required
Timelines & Dates MAE
Time lines / Dates for MAE instructions::: updated 8/22/2006 1. 5/5/2005 – MAE was published by CMS with implementation July 5, 2005 2. MAE relates to MRADL (mobility related activities of daily living) 3. August 24, 2005 – CMS issues regulations that CMNs no longer required for Power w/cs and POVs 4. September 14, 2005 – Evidence of Medical necessity – PMD claims 5. **No CMN required for Manual Sept 23** 6. transitional CMNs 10/01/05till{4/1/06} – 7. Face 2 Face - 10/25/05 (45d grace existing pts.) 8. 3/10/06 – Memo from CMS – 30days – detailed order (1/1/06-4/1/06) will not be required. F 2 F still) 9. 3/31/06 IFR fact sheet *45d*- NOTE date 10. Federal Registar 4/5/06–will be final in 60days—*****6/05/06***** implementation Date STAMP/or equivalent doc. MD 6/5/06 7/11/06 updates – 120 days (p F2F) deliver chair (8/24/06) Detailed order must include brief description of base, options to be billed – your charge and Medicare allow / or N/A *8/24/06* ___ ___---- Also required for manual wheelchairs --- Must sign attestation that you have no financial involvement with PT/OT 8-10-06 August 15 new LCD for PMDs out to become effective October 1, 2006 with new 64 codes (groups of codes) *** this was opened for comment for 45 days*** January 2008 – grp 2pwc with single power option and above and all grp 3,4, or push rim activated device April 1, 2008 supplier must have a RESNA certified ATS/ATP employed who is directly involved in the evaluation (can be contracted employee) – MUST DOCUMENT the involvement.
November 2009 - MUST not have any thing in the body of the 7 element order {ie: can be simply power wheelchair/POV/scooter} that would “appear” to be leading the physician.} 1/1/2011 –pwcs K0813 through K0831 & K0898 went into capped rental – usrehab.com to get amounts to bill
Page 2 revisions 2011
February 4, 2011 the LCA became effective --- March 14 POLICY**** cushion to deny.
th – items Group 2 (K0806/K0807(POVs***) & K0830/K0831(PWCs) & Group 4 PMDs*** fell into statutorily non covered in the LCA and ***** CHANGED Back on June 1, 2011 with July Revision to LCD Manf chair that has both a captain seat code and rehab seat code such as K0822 – can’t bill essential cushion and back – both will deny since CMS states that if they need rehab seating it would be specialty seating only. A captain seat would be comparable to an essential seat and essential back. Used to have medical necessity reasoning now has statutorily non-covered reasoning so will cause both the base and
Who can order?
The practitioner caring for the patient orders the equipment.
Practitioner can be : physician, licensed nurse practitioner, clinical nurse specialist or physicians assistant.
The ordering practitioner must have their own UPIN number. (NPI-May- 2007) The physician does not have to review and sign behind the LNP; PA or CNS
When did this start?
May 5, 2005 MAE was published by CMS - effective 07/05/2005 8/24/2005 CMS issued no CMNs for PMDs 9/14/2005 – Evidence of Medical Necessity was issued relating to PMDs ***9/23/2005*** No CMNs for Manual w/cs 10/01/2005 – Transitional CMNs required 3/10/2006 – Memo from CMS – Claims to be paid based on current policy (ie: RX does not have to contain the 7 elements & the information does not have to be to the supplier in 30 day time frame) 4/1/2006 – 30d changed to 45 d effective 06/05/2006/ date stamp/equal required on documentation from physician (power) 7/11/06 – 120d to deliver chair effective 8/10/06(power) 7/11/06 -Attestation statement from supplier that there is no financial relationship with PT/OT doing eval- 8/10/06(date of bill driven) – detailed written order needs to include: brief description of item ; HCPCs code your charge-Medicare allowable prior to delivery (on/after 8/24/06) (power) May 1, 2007 – KX modifier required for all manual w/cs and accessories 2008 (coding for manual wheelchairs to be revised) watch VGM discussion board & your list serve from the DME MACs October 2009 DPT required for base and all accessories
CMNS as processing tools
Electronic payment of claims was guided by the answers on the CMN, we as suppliers had a false sense of security, because we felt if the CMN was completed correctly we were covered on a post pay audit.
The fact is that each DMERC/DME MAC was & is required by law to audit for improper use of CMNs.
The old pay and chase game.
Some took advantage of this system so we get the “boot” end of the reaction to the fraud and abuse (mistakes???? etc) *******
Basically --The Medical Necessity information required needs to be in the patients medical file (Physicians
progress notes -SNF-Hospital-PT/OT-home health) etc.
NO SUPPLIER GENERATED “PHYSICIAN FORMS” OK for blank 7 element order --
Manual W/Cs – Audit Requests
On post pay –reviewers may expect to see: 1. Copy of order (if verbal will need a confirmation of verbal/phone order) 2. Detailed written order which is to be completed by supplier for physician/practitioner to review, sign & date (prior to bill on manual).
3. Beneficiary Authorization 4. Proof of delivery 5. Medical records which documents need.
6. Proof patient is able to use chair safely & it is able to be used through out their environment.
Medical Records – what are they?
Medical records can consist of: Physicians/practitioners’ progress notes Nursing home discharge summary Hospital discharge summary Home health notes Any clinicians’ notes or evaluations (PT/OT) etc.
What are they expecting to see?
Documentation relating to the impairment of mobility which could be in the form of a history and physical, follow up notes relating to disease progression, surgery notes stating date of surgery, outcome of treatments tried and failed - Documentation as to why a cane or walker would not meet the functional needs of the patient. Sometimes just the diagnosis would relate to this but if in doubt request a PT/OT eval. Diagnosis such as gait instability / frequent falls /frail individual which would also need explanation of need for specific base.
OH – NO-- where do I get this?
Some of the information for basic manual wheelchairs will come from your own “environmental” evaluation or PT/OT notes which would require ordering practitioner to review and sign off on.
Each manual base will require something stating why the lower level base would not meet needs.
The clinical notes from a clinical area will drive payment – Home health; discharge H & Ps (summaries) form SNFs/ICFs/ Hospitals / Rehab hospitals etc.
Accessories
All additional accessories that were formally place in part C of the CMN will require a detailed written order including codes Needs to state the base/ HCPCs code brief description – your charge and Medicare allowable that has been reviewed by the physician/ordering practitioner, signed and dated.
A lot of the manual bases can be explained with diagnosis alone (stroke/bi-lateral amputee etc) but look for discharge summaries from hospital/SNF/Rehab facilities for additional information.
Mobility is specific to functional MRADLS & not just diagnosis driven so watch the cardiopulmonary diagnosis since these sometimes require specific documentation relating to the ADLS and caregiver assistance. KX -- required on base and all accessories 5/5/07 KE -- req. all accessories that could be billed on cb pwcs. (1/1/09) “Fit the patient to the chair and not the chair to the patient”