Transcript Mobility Assist Equipment CMS Decision Memo

MAE from a simple cane to High End
Power – Documentation that HAS to be
there.!
A to Z It is not JUST About POWER
reviewed and updated 8/12/2014
FOR
ALPINE MEDICAL REHAB CONFERENCE
OCTOBER 2-3 2014
BY
Peggy Walker, RN
Director of Reimbursement Services
US Rehab/VGM
803-754-2090--800-401-3643
803 754 2091
[email protected]
Mobility Assist Equipment
effective5/5/05-implementation 7/7/05
THE DECISION THE SAGA BEGINS
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CMS determined that Beneficiaries might need help
to complete adls. {DUH}
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If – they have a personal mobility deficit sufficient to
impair their participation in mobility related ADLS
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Mobility related ADLS such as toileting, dressing,
feeding , grooming & bathing –
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IN - :”customary locations in the home” OKOKOK -What does this mean?
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BE CAREFUL about assisted living and needing to
go to dining room – not written anywhere and on
reviews money is being recouped – is this where
they usually go for all meals? Can they prepare
meals in apt?
Modification of the Medicare National
Coverage Determination Manual
effective date 5/5/05 implementation 7/5/05
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Replace coverage indications on:
ALL MAE
CANES (all types); Walkers; crutches; gerichairs; 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
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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
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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
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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?
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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
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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
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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.
Safety Issues
1.
a.
b.
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Has the beneficiary/caregiver demonstrated the
capability & ***willingness*** to operate the
MAE safely?
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
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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. NPI
F2F IMPLEMENTATION FOR MANUAL W/Cs and other items included on
“the list” as of July 1, 2013 – active reviewing delayed till “A” date 2014
Completed “PRIOR TO DELIVERY” AS OF July 1, 2013
Documentation
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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
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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
***** NOTE***** first
level of MAE and has to be
ruled out if going to next
level !!!!!
Environment Assessment
Can the beneficiary’s typical environment support the
use of w/c including scooters/POVs/MWCs?
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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)
Home Assessment for Manual wheelchairs
Must be documented in the medical record or elsewhere by the supplier:
May be done directly by visiting the beneficiary’s home; or
May be done indirectly based upon information provided by the
beneficiary or their designee:
 At time of delivery, supplier must verify that the home can
accommodate the item delivered. If picked up from supplier than you
should do a follow up call and verify ability to use within the home.
Manual vs Power
Upper extremity functions
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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.
KE to be used on complex rehab mwc July 1, 2013 rd 2 CB
kicked in
 Categories:
 Capped Rental:K0001, K0002, K0003, K0004, K0006,
K0007,E1031, E1038, E1039 *K0009*
E1161 and
all pediatric tilts as of 4/1/2014 ATP/therapist 3/1/13
 Inexpensive Routinely purchased: K0005; (Rent
/Purchase) {*ADMC} ATP/therapist 3/1/2013 req.
 Other Wheelchair Base: K0009 {ADMC}* Changed to
Capped rental 1/1/2013
 * Can go to ADMC but not required. Requires ATP/and
therapist evaluation March 1, 2013
MWCs codes to be revised
will be done by dmepdac no updates on this
KE modifier req. 1/1/09
accessory that could’ve been billed on a competitive bid pwc rd 1 rebid
KY Modifier req 7/1/2013 on accessories billed on CB items in Round 2
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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**(prior) to July 1,
2013 -- there still must be an ordering practitioner
involved for ANY DME. **** F2F*** implementation
July 1, 2014 with delay in active reviewing until “A”
date in 2014 – is now required.
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
 REMEMBER YOU MUST RULE OUT LOWER LEVEL ITEM BEFORE
GOING TO NEXT LEVEL UP.
K0003 – K0004
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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. MUST BE DOCUMENTED
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?
F2F required as of July 1, 2013 implementation – with delay
in active review until “A” date in 2014 --- No active auditing
from any auditors (except CERT) till implementation date is
announced (but only for F2F) Active auditing for the DWO is
January 1, 2014 --
K0005 (can go to ADMC)
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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
March 1, 2013 complex RTS employ ATP & Clinical eval
F2F required july 1, 2013 implementation
K0006 – K0007- K0009
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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 – *** changed to CR 1/1/2013*** with an allowed
amount of $77.00 per month Basic mobility information
required as well. The LCD still says other wc base as of this
date 11/21/2013 but there is no directions on coverage in the
policy itself just the code and description.
NOTE – these are all being recoded ck pdac before providing
under this code
F2F required July 1, 2013 with delay in active review till “a”
date in 2014
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)
***(language rev may 2012 must include large wheels so pt can
self propel) this means that are wheels are part of base and to be
billed as a separate item ***
 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.
 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” revised Sept 2013
 MARCH 1, 2013 requires ATP and Clinical evaluation
F2F implementation 7/1/2013 delayed “actively reviewing”
10/1/2013 then sept 8 delay till “a date in 2014”
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Active reviewing of DPD 1/1/14
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Moving to CR as of 4/1/14 -
POVs-ASSESSMENT
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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
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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, 2005**
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
Timelines and dates p 2
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K0005 and E1161 will require ATP and
clinical evaluation March 1, 2013
F2F implementation July 1, 2013
With active reviewing delayed till A date in
2014
revisions 2011
February 4, 2011 the LCA became effective --- March 14th – 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
POLICY****
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
cushion to deny.
LEAST COSTLY ALTERNATIVE
Who can order?
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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
E1161 and pediatric tilts
E1232/E1233/E1234 also ped bases E1234-E1238
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MWC Accessories that will be capped rental as of
4/1/14
E1014 (reclining back ped w/c)
NOTE many pwc accessories will go into capped
rental as of 4/1/14 but not for complex bases.
Allowed amt for rental is $258.74 with total
purchase being $1811.18 was $2587.73 loss for
base $776.56
When did this start?
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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
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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
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On post pay –reviewers may expect to see:
1. Copy of order (if verbal will need a
confirmation of verbal/phone order)*** must be
detailed written order prior to delivery 7/1/2013
2. Detailed written order which is to be completed by
supplier for physician/practitioner to review, sign &
date (prior to bill on manual). *** PRIOR TO
DELIVERY AS OF JULY 1, 2013***
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?
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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?
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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?
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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/
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
KY req rd 2 accessories (IMPORTANT FOR COMPLEX REHAB ON
INITIAL AND REPLACEMENT PARTS) NOT paying correctly 11/13
NEW CODE FOR ACTUATOR REPLACEMENT E2378**** 1/1/2013
“Fit the patient to the chair and not the chair to the patient”
KY MODIFIER NOT PAYING CORRECTLY WITH COMPLEX ACCESS.