Transcript Community Forum - Alpine Rehab Conference

Mobility and Beyond
Community Forum update to assist
with training of your referral
sources
F2F required July 1, 2013
IMPLEMENTATION WAS NOT DELAYED
Actively reviewing delayed till 10/1/2013
9/1/2013 actively reviewing delayed again
till “A” date in 2014
Actively auditing for WOPD 1/1/2014
9/9/2014
ALPINE MEDICAL
REHAB CONFERENCE
OCTOBER 2-3 2014
Presented by
Peggy Walker, RN
Director of Reimbursement Services
US Rehab/VGM
800 401 3643
[email protected]
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A Brief outline for referral sources
Peggy Walker, RN Ronda Buhrmester
US Rehab/VGM
800-401-3643
888-665-6518
877 907 3862fax
855 262 3821fax
Dan Fedor ([email protected]
fax 844 307 5729
ph 844 794 8459
[email protected]
[email protected]
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Medicare What Works?
Updates MAE
• In all instances for any type of DME the medical records must contain
information which supports the medical necessity of the item ordered.
Medical records could also be PT/OT evaluations; home health records;
hospital discharge summaries; rehab hospital notes; Nursing home records
etc.
• **The physician/Physicians’ assistant/ Licensed Nurse Practitioner who is
caring for the patient & has their own NPI number can write & sign orders,
complete & sign CMNs (Certificates of Medical Necessity) for documentation
of medical necessity for equipment they feel the patient is in need of. (F2F
implemented 7/1/2013 physician must review and sign off on PA/LNP/CNS)
Progress notes *PRIOR TO PROVIDING THE EQUIPMENT*
• ** Medical equipment is covered for in home use and there are specific
requirements of documentation for payment to be received.** IF IT IS NOT
DOCUMENTED IT IS NOT COVERED!
• NOTE – Bathroom Equipment is not covered (anything that goes through the
bathroom door) by Medicare
Medicare will pay for what the patient actually needs for functional mobility
within the home (they do not pay for prevention) exception being overlays
for support surfaces.
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Canes/Crutches/Walkers
Mobility follows an algorithmic approach in which each item has to be justified
by ruling out the lower level item (the face to face requirements affects all manual wheelchairs as of 7/1/2013)
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Canes/crutches are covered when prescribed by a ordering practitioner for a patient with a
condition causing impaired ambulation and when there is a potential for ambulation.
A white cane for a blind person is non-covered since it is a “self help” item.
Walkers Standard walker is covered if prescribed by physician for a patient with a medical condition
impairing ambulation & there is a potential for ambulation, AND there is a need for greater
stability and security than provided by cane or crutches.
Heavy duty walker E0148; E0149 is covered for patients who meet coverage criteria for a
standard walker AND who weigh greater than 300 pounds. Use KX modifier.
E0147 - Heavy duty, multiple braking system, variable wheel resistance walker is covered
for patients who meet criteria for a standard walker AND who are unable to use a standard
walker due to a severe neurologic disorder or other condition causing the restricted use of
one hand. (Obesity by itself is not sufficient reason for an E0147 walker) Manufacturers,
name, make, model & note or other documentation from physician detailing functional
limitations which preclude the pt. using another type wheeled walker & diagnosis causing
this limitation.
Enhancement accessories of walkers will be denied as non-covered.
Leg extensions are covered for patients 6 feet tall or more.
The supplier must use specific modifiers for certain items if weight specific items are
required the supplier needs to have a “documented” weight in the actual medical recordsIt is very important for referral sources to understand that in obesity Medicare covers
according to WEIGHT AND NOT MEASUREMENTS
**IF not Documented it is not covered***
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Manual Wheelchairs
Note F2F & WOPD affects all mwcs 7/1/13
What is the mobility impairment that prevents the patient from ambulating within the home? (Diagnosis)
Why a cane or walker can not meet the patients’ needs within the home.
When going from a lower level base to a higher level base such as from a standard manual w/c to a light
weight additional information would be needed.
Why patient is unable to self propel a standard manual w/c within the home – that they can self propel the
K0003 (light weight) *** Note*** this can be related to information conveyed to the physician by even the
supplier if diagnosis & condition would back up the statement – ie: the supplier tries the patient in a
standard manual wheelchair and they could not self propel because it was too heavy for them but when they
tried the (K0003) light weight w/c the patient could self propel. The medical records established need for a
manual w/c.
The K0003 is a base that the patient themselves have to be able to self propel and not for caregiver to be
able to transfer to car. (light weight)
The K0004 is covered if there is a need for a seat width, seat depth, seat to floor height or back height
adjustability not available in “ANY” lower level base and patient spends at least 2 hours a day in chair and it
will be needed long term. >3 months (high strength light weight) Not for basic post op patients. OR the
patient is highly active and spends 2 hour or > up in chair per day.
The K0005 has to be able to self propel/ highly active/ what is avail. on K-5 that is “NOT” avail. on K0004 ***
This is a MUST*** ADMC available {ultra light weight} full time mwc user – MRADLs both inside and outside
the home– need for maximal axle adjustability / camber/ back adj etc.
The K0006 is heavy duty – needs manual base – weight >250#s
K0007 – extra heavy duty – needs manual base – wgt >300#s
K0009 – other w/c base – can’t use any lower level base & why (mostly bariatric)
E1161 (adult) manual tilt in space – why standard with recline will not meet needs – specific to weight shifts
and specialty positioning needs. Pediatric tilts can be billed to Medicare E1231 – E1234 ADMC available
TRANSPORTER chair s are covered “in lieu of” (instead of standard MWC) must meet need for mobility
within the home / can’t use a cane or walker –
*** All MANUAL WHEELCHAIRS MUST HAVE F2F DOCUMENTATION AND WOPD ***PRIOR TO DELIVERY***
WITH ACTIVE AUDITING OF THE WOPD STARTING 1/1/14 BUT CAN GO BACK TO 7/1/13*** DMEMACS
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Bedside commodes/patient lifts (hoyers’)/seat lift mechanisms
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Bedside commodes are only covered if the patient is room confined or unable to get to
toilet facilities. (Not covered to be placed over the commode in the bathroom.) (need has
to be documented)
Heavy duty commodes width =to or > than 23 inches – weight capacity 300 pounds or
more.
Detachable arms are covered when used to facilitate transferring the patient or if the
patient has a body configuration that requires extra width. *any commode*
**** supplier must have documentation on file as to why patient is room confined or
unable to access toilet facilities*** NOT covered to fit over commode in bathroom.
Patient lifts (Hoyer or other types) - covered if transfer between bed and a chair,
wheelchair, or commode requires the assistance of more than one person and, without
the use of a lift, the patient would be bed confined. *** KX*** is required
Lift Chairs - Patient must be able to ambulate once standing (cannot be used in
conjunction with a w/c or POV (must be non-amb. with these) F2F RULES APPLY**
Have severe arthritis of hip or knee or have severe neuromuscular disease. Diagnosis
required
Must be a part of the physicians’ course of treatment and be prescribed to effect
improvement, or arrest or retard deterioration in the patients’ cond.
Pt. must be completely incapable of standing up from any chair in his/her home. ( The fact
that a patient has difficulty or is even incapable of getting up from a chair, particularly a
low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who
are capable of ambulating can get out of an ordinary chair if the seat height is appropriate
and the chair has arms.)
Once standing, the patient must have the ability to ambulate
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POVs(scooter)-**Hospital Bed**
***Note effective 8 1 2013 Pillows / wedges ruled out / considered no longer required. ***
POVS [Scooters] F2F with ordering practitioner required
• The patient’s cond. is such that a scooter is required for pt. to complete MRADLS in their home.
{The scooter must be able to fit and be used within the home.} Not considered for coverage if just
needed for outside the home only.
• Unable to operate a manual w/c.
• Capable of safely operating the controls of a POV.
• And can transfer safely in & out of the POV & has adequate trunk stability to be able to safely ride
in the POV.
• Order with all 7 elements required (ordering practitioner)
• In home environmental evaluation required at time of or prior to delivery. (supplier)
• *** January 2011*** Group 2 standard pwcs (K0813-K0831 & K0898) go into capped rental but
scooters will remain in purchase category.
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F2F RULES APPLY TO ALL HOSPITAL BEDS AS OF 7/1/13 ACTIVE AUDIT 1/1/14 WOPD CAN GO BACK
TO 7/1/13 – DOCUMENTATION ACTIVE AUDITING DELAYED TILL **A** DATE IN 2014 --
BEDS: Must have Medical Necessity documentation (no auto down codes) If you bill fully electric it
will deny and not down code 1/1/2011
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1. Semi-electric -- Pt. requires positioning of the body in ways not feasible with an ordinary bed
in order to alleviate pain;
• Requires the head of the bed to be elevated more than 30 degrees most of the time due to CHF,
COPD, or problems with aspiration.
• **** Pillows or wedges must have been tried and failed to achieve the desired clinical
outcome***NOTE THIS*** removed 8 1 2013 effective
• Requires traction equip. which can only be attached to a hospital bed.
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• CMNs no longer required but Medical Necessity information must be in patients’ medical records.
Specialty Mattresses
• Specialty Mattresses: Group 1 (over lays) Group 2 [pressure reducing] &
grp 3
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Coverage
• Completely immobile - i.e. Pt. cannot make changes in body position
without assistance
• Limited mobility - ie pt. cannot independently make changes in body
position significant enough to alleviate pressure.
• any stage pressure ulcer on the trunk or pelvis
• impaired nutritional status
• fecal or urinary incontinence
• altered sensory perception
• compromised circulatory status
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Group 1 (mostly over lays ) Criteria 1, or criteria 2 or 3 and at least
one of 4-7.
• F2F applies as of 7/1/13 --
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Group 2 specialty mattress
• Group 2 (powered pressure reducing mattresses)
• (Covered if meets: Criterion 1& 2 & 3 above OR criterion 4 OR criterion 5
& 6 below.)
• Multiple stage II pressure ulcers located on trunk or pelvis
• Pt. has been on a comprehensive ulcer treatment program for at least
the past month which has included the use of an appropriate group 1
support surface.
• The ulcers have worsened or remained the same over the past month.
• Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis
• Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk
or pelvis (surgery within the past 60 days)
• the patient has been on a group 2 or 3 support surface immediately prior
to a recent discharge from a hospital or nursing facility (discharge within
the past 30 days).
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Group 3 specialty mattress {require
WOPD}
• Group 3 (air-fluidized bed) ALL of following
• Stage III (full thickness tissue loss) or stage IV (deep tissue destruction)
pressure sore.
• Bedridden or chair bound as a result of severely limited mobility.
• In absence of an air-fluidized bed, the patient would require
institutionalization.
• The air-fluidized bed is ordered in writing by the patient’s attending
physician based upon a comprehensive assessment and evaluation of
the patient after conservative treatment has been tried without success.
Treatment should generally include:
• Education of patient and caregiver on the prevention and/or
management of pressure ulcers.
• Assessment by physician, nurse, or other licensed healthcare practitioner
at least weekly;
• Appropriate turning & positioning.
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Responsibilities - Ordering Practitioner
PMDS
Face to face in narrative format (the way they normally
chart an office visit) ***Soap Notes*** 9 points to be
covered. Algorithm A good order with the 7 elements –date of face to face can
be date physician saw patient or date reviewed PT/OT for
completion of F2F
Review and sign off on PT/OT evaluation if needed
Review and sign off detailed product description from
supplier
Make sure supplier receives all documentation within 45
days of the “completion of” F2F
Legible signatures or print name below Make sure
signature is dated.
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Physicians letter (SOAP NOTES
Mobility Assistive Equipment
As you may be aware, on May 5, 2005, CMS issued a memorandum relating to Mobility Assistive
Equipment (MAE) such as canes, walkers, manual wheelchairs, scooters and power
wheelchairs. This letter addresses only POVs/scooters and power wheelchairs – which are
described by the term power mobility devices (PMDs).
On or after 10/25/2005, for all power mobility devices a face to face examination by the ordering
practitioner is required. Medicare will reimburse you for the actual face to face billed under the E
& M code of 99211/99212/99213/99214 (according to level of visit) as well as a new
G code [G0372- allowed amount of approximately $21.60 according to your state *** used to bill
for faxing the documentation to supplier within 45 days]. During the face to face there are several
areas which you would be required to address & write in your progress notes. We have included a
brief summary to assist you in making sure all areas required have been addressed. The face to
face eliminates all forms/CMNs previously required for the power mobility devices.
The items to be addressed relates to the patients’ physical & cognitive condition and functional needs
for mobility assistance “in the home”. Remember, Medicare does not pay for equipment which is
only needed outside the home. This basically means that you state: why your patient is unable to
ambulate in the home, why a cane, walker, or manual wheelchair would not meet the patients
need for mobility within the home & you write the order for the POV/scooter or power
wheelchair. The information can be part of the patients’ already existing records and you may
want to send copies of previous visits to ensure the information shows the progression of the
patients’ condition which requires the power wheelchair or POV/scooter. The supplier will
complete an in home environmental evaluation to ensure that the patient is able to safely use the
item provided. The supplier completes a detailed written order (equipment evaluation) for you to
review & sign off on. You will need to send your information to the supplier within 45 days after
the face to face. ***Progress (SOAP) notes***
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Good Order Example
7 Element order
1. Patient Name::
2. Date of completion of (F2F):__________________
3. Diagnosis (s) relating to mobility impairment: _____________
4. Length of need: _________________
5. Mobility base required:
__________________
6. Signature:_______________ 7. Date ________________ NPI ___________
(PRINT NAME) _______________
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PT/OT Responsibilities
• Clinical evaluation of patients needs within the
home.
• Goals – be realistic about what they need to do and
how they can accomplish it independently.
• MRADLS within the home environment
• Get evaluation to physician in timely manner – let
supplier know it has been sent.
• Make sure they note that ATP was present &
participated in the evaluation (if there) *** this does
not mean that the ATP does not have to complete his
equipment recommendations and evaluations as
well**** that want “proof” of ATPs direct
involvement
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Example PT/OT evaluations
remember this is just an example
Evaluation – Mobility Assist Equipment
HISTORY/DIAGNOSIS/PROGNOSIS:
____ is a ____ yo male/female with a diagnosis of ____. Pertinent Medical history includes ________. He/she
is ___tall & weight _____. Prognosis poor, good, fair etc.
Assistance:
He/she lives in a w/c accessible/non-accessible house alone/with____. He/she has assistance/no assistance.
Caregiver is able/unable to assist with ____
Prognosis poor, good, fair etc.
HOW NEEDS ARE MET TO DATE:
Presently using a ______ that is ____ years old & in (fair, poor, good) condition. A change is needed because:
_____________________________.
MOBILITY: ***CAUTION*** REMEMBER what they can do independently!!!
___ is (non-ambulatory - ambulates short distances with assistance of - etc.) high risk of falls?
STRENGTH, FUNCTIONAL LEVEL & ADLS: Patient is dependent/independent/requires minimal/maximal assist
with bathing, dressing, toileting, preparing simple meals etc. Upper extremity strength is ____ Lower extremity
strength ___. Movement of extremities _____. Passive range of motion _____ upper & lower extremities.
Sitting balance is _____ static & ____ dynamic. Circulation ___ .
COGNITIVE ABILITY: Alert - oriented - MR - decreased cognitive status etc.
Compliance with use of equipment?
Safety Awareness / in home trial with MAE – must be completed for all power chairs. *** manual can be a
verbal/telephone interview with patient or family member/caregiver but should be followed up*** If the
manual chair being provided is needed specifically as related to environment than an actual visual evaluation
would have to be completed by suppler***
PREDOMINANT TONAL PATTERNS: Spasticity lower extremities - etc.
POSTURAL IMPAIRMENT: Mr./Mrs. /Ms sits with fixed kyphosis, scoliosis, wind swept etc. – Contractures of
_____ etc.
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Evaluation p-2
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specific base required --Power wheelchair / Scooter)
Cushion - Name, make, model MSRP & why this is needed above a lower level cushion. What was used in past &
why is change needed? (New codes 08/01/2006) Use KX modifier except on general use cushions.
Back - Name, make, model no., MSRP & why this is needed above a regular sling back or planar back with 1”
foam. Again what was used in the past & if changing why? (Use KX modifier except on general use and Clinical
evaluation required on “custom” codes) New codes 08/01/2006 RESPIRATORY STATUS: COPD, Asthma, no
problems etc.
SKIN CONDITION: History of decubi rt. ischeal - no break down - etc.
VISUAL/HEARING: Presents with limited vision - WNL - Hearing WNL etc.
PLANNED USE FOR CHAIR: What are patients daily activities that they require this level of chair? This is specific
as related to MRADLs.
CAREGIVERS’S CONCERNS: Who was involved in evaluation? What do they see as needs for their family
member, patient, friend? How available are they? Time spent with patient _______. Are they available & willing
to assist patient with care of base being provided?
Risk to patient (injury) – history of frequent falls (be specific) One fall a year would not be something that would
be acceptable.
ESTIMATED NUMBER OF YEARS CHAIR WILL BE USED/ FUTURE NEEDS ADDRESSED: Permanently / will they
need an add on at a later date? Prognosis is very important when choosing specific bases because of need for
future changes to meet functional decline.
Evaluators names & titles. PT/OT/CRTS/ATS etc.
EVALUTION for specific equipment (example)
Equipment (base) & explanation of need for specific accessories.
Frame - Name, make, model no. & MSRP - Why this frame was needed above any lower level chair.
Tilt/Recline: Name, Make, Model no. & MSRP. - What is the condition that requires this specialty item. What
was used in past? Why is change needed?
Seat - Special width/depth (name, make, model of base & why this special sizing was needed). MSRP (if not
already coded for
Legrests : If power Name, make, model & MSRP & why needed - If manual why needed over regular leg rests.
(edema, fixed hip angle, cast etc.)
Armrests: Adjustable height, arm troughs etc. - Why needed over standard.
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Evaluation P-3
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Other Special Considerations: Make sure you always give the name, make, model, MSRP of
the specialty item and the condition which requires the item as related to medical
necessity & not convenience.
** Past history of use of same or similar equipment must always be addressed***
If you are using a special item and the standard item has an existing code for any accessory
you must state why the standard item would not meet the needs of this particular patient
as related to Medical Necessity & not convenience. The item must address the needs of
the patient both present and future & not care givers specifically.
MEDICAID --- Additional Information
Make sure that you give other options/bases (with pricing) tried and why the other
option/base did not meet the needs/goals for the particular client/patient. Use Medicaid
codes as required. (This is good to use with Medicare as well.)
In many states Medicaid wants more detailed information on products such as breaking
out the hardware from specific items and giving Medical Necessity for this as well. ie:
Laterals – Hardware to attach laterals. (why detachable/swing away needed over fixed
hardware)
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Suppliers Responsibilities
• Assist PT/OT with evaluation and equipment information
• Gather all information from ordering practitioner/clinicians/medical
records etc.
• Do in home evaluation at time of/or prior to delivery (after 7
element order has been received).
• Detailed product description must be completed prior to delivery
• Date stamp all documentation received
• Make sure all other routine information is in chart.
• Attestation statement required on all group 2 single power options
and above –
• Completion of ATP evaluation for higher end power/E1161s /K0005s
• ALL signatures must be legible or have printed name below = person
signing delivery ticket must date signature.
• MAKE SURE TO GET PURCHASE OPTION LETTERVFOR ALL
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PURCHASED
POWER WHEELCHAIRS!!! This is still required.
IN Home Evaluation Example
Environmental Assessment for Mobility Equipment
ABC Company
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Patient Information:
Name:
Address:
Date of Assessment: ____________
Completed by:__________________
Housing Type: Apartment – Single story – two story – Mobile home etc.
Comments:
Surfaces: Carpet ____ Linoleum _____ Hardwood ______ other _______
Comments:
Space:
Cluttered: ______ Open ______ Small rooms _____ Hallways
Comments:
Rooms Accessible: Bedroom___ Bath___ Living/family Room __ Dining/Kitchen___
(ramps or steps?)
Comments:
Measurements:
Entry Doors: width _______ Bathroom ______ Kitchen _____ Bedroom ______
Hallways _______ Other _______
Entrance: Ramps – steps – low threshold
Outside access: paved – gravel –dirt
Recommendations:
Patient and/or caregiver/family member is willing and able to use the mobility device safely and adequately to assist with
MRADLs in the home. Y ______ N ______
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Patient and/or caregiver/family member was educated on care & safety with use of equipment. Y __ N__ He/she is able
to use in the home. Y __ N ___
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Patient / Caregiver:
Signature ______________ Date ____________ Why patient unable to sign if caregiver signs.
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Suppliers
Signature ______________ Date _______ Print name ____________________
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Attestation Statement
to be completed by supplier or PT/OT
Company Letterhead
This is to attest that ABC company has no financial
relationship with (name, PT/OT) completing the
evaluation for (patient name) on (date).
Signature:
Title:
Date:
NOTE: needs to be specific to patient /Clinician/date /
*** WE HAVE SEEN DENIALS FOR NOT HAVING AN
ATTESTATION STATEMENT RELATING TO PHYSICIANS
SO JUST ADD HIS/HER NAME TO IT***
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Detailed Product Description
base & accessories requires name/make/model//number
Company Name
Address
Phone:
Fax:
Patient Name:
Address:
Date of F2F: THIS IS START DATE OF ORDER
Dear Dr. _____ in order to assist your patient in receiving the proper mobility equipment
and/or specialty seating we are required by Medicare to complete a description of the base
and all items we are providing to the patient for your review. Upon assessment of the needs
of the patient in their usual environment we feel the following product and seating will best
meet Mr/Ms/Mrs _________ functional mobility needs. If you agree please sign and date
below.
Eq: _____HCPCS Code_____
COMPLETE description of all accessories as well as base (name,model #)
NO PRICING REQUIRED 6/1/2011
Physicians signature ______________ Date _____________ NPI _____________
Print name _____________
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Basic Equipment package p-1
(power)
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Belts(E0978)
Battery chargers(E2366)
Complete set of tires and casters (any type)
Controller & input devices***NOTE*** if a code specifies and
expandable controller as an option (but not a requirement) at
the time of initial issue, it may be billed separately (if
medically necessary)
Leg rests (ELRs separate)
Fixed/swing away detachable foot rests/include ang. Adj.
Weight specific components according to sub division
Armrests (hgt. adj. will still be separate)
Upholstery
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Basic Equipment Package p-2
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Shoulder harness/straps/vest may be billed separately
Seat width/depth exceptions : grp 3 & 4 pwcs with a sling/solid/back can bill
separately for:
*standard –seat w/d > 20 inches
*heavy duty – w/d > 22 inches
*Very HD – w/d > 24 inches
*Extra HD – no separate billing
* Back width exceptions: grp 3 & 4 pwcs with sling/solid seat/back can bill separately
for:
*standard – width > 20 inches
*HD – width > 22 inches
*VHD – width > 24 inches
*Extra heavy duty – no separate billing
K0108 is code to use for width/depth making sure you give name, make, model and
MSRP in narrative.
Adj angle foot plates can be billed on grp 3-4 & 5 on initial issue.
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Summary
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What is “intended” as a meaning and what is actually documented is a difference in
actual coverage.
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The algorithm states that physician must address why a cane – walker – manual chair
will not meet needs. – This needs to be addressed in all categories {even Quads}
and replacement bases (except if <5yrs and destroyed by catastrophe
(fire/flood/theft etc)
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F2F date means F2F date and not “appointment date” * new items require F2F July
2013-
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The progress notes must address that patient is in for an evaluation for mobility (not
follow up of multiple medical problems; FU for surgery etc.) Ordering
Practitioner***NO FORMS*** can not stand alone for documentation purposes ***
must have good Medical necessity clinical documentation on any post pay review for
any item. They will ask for previous progress notes in some instances
(cardio/pulmonary diseases and conditions)
A good progress notes relates to the need for the equipment being ordered and
should discuss the individuals functional limitations as related to the specific
equipment being ordered.
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Note
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if it is not documented it is not covered!!!
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