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
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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
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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.
***POWER (any type) must also include the actual date of F2F***
{7 element order}
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
Environment Assessment
Can the beneficiary’s typical environment support the
use of w/c including scooters/POVs?
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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)
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.
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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.
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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 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
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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.
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)
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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
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 – 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
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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
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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**
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 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.
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
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)
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?
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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)
“Fit the patient to the chair and not the chair to the patient”