Mobility Assist EquipmentMobility Assist EquipmentA to Z It is not JUST About POWER A to Z It is not JUST About POWER

Reviewed and updated 9/26/2011Reviewed and updated 9/26/2011Jackson MS 10/4/2011Jackson MS 10/4/2011

Peggy Walker, RNPeggy Walker, RNUS Rehab/VGMUS Rehab/VGM

803-754-2090--800-401-3643803-754-2090--800-401-3643803 754 2091803 754 2091

peggy.walker@vgm.comV fax 877 907 3862V fax 877 907 3862

Mobility Assist EquipmentMobility Assist Equipmenteffective5/5/05-implementation 7/7/05effective5/5/05-implementation 7/7/05

THE DECISION THE SAGA THE DECISION THE SAGA BEGINSBEGINS

CMS determined that Beneficiaries might need help CMS determined that Beneficiaries might need help to complete adls. {DUH}to complete adls. {DUH}

If – they have a personal mobility deficit sufficient to If – they have a personal mobility deficit sufficient to impair their participation in mobility related ADLSimpair their participation in mobility related ADLS

Mobility related ADLS such as toileting, dressing, Mobility related ADLS such as toileting, dressing, feeding , grooming & bathing –feeding , grooming & bathing –

IN - :”customary locations in the home” OKOKOK -- IN - :”customary locations in the home” OKOKOK -- What does this mean?What does this mean?

BE CAREFUL about assisted living and needing to BE CAREFUL about assisted living and needing to go to dining room – not written anywhere and on go to dining room – not written anywhere and on reviews money is being recouped – is this where reviews money is being recouped – is this where they usually go for all meals? Can they prepare they usually go for all meals? Can they prepare meals in apt?meals in apt?

Modification of the Medicare Modification of the Medicare National Coverage Determination National Coverage Determination

ManualManualeffective date 5/5/05 implementation 7/5/05effective date 5/5/05 implementation 7/5/05

Replace coverage indications on:Replace coverage indications on:

ALL MAEALL MAE CANES (all types); Walkers; crutches; CANES (all types); Walkers; crutches;

geri-chairs; power & manual w/s; POVs ; geri-chairs; power & manual w/s; POVs ; special size w/csspecial size w/cs

Rolling chairs will maintain the coverage Rolling chairs will maintain the coverage limitations on caster size (geri)limitations on caster size (geri)

Determination of type of Determination of type of deficitdeficit

Use of an algorithm process (ALL MAE)Use of an algorithm process (ALL MAE) Assessment of individual needsAssessment of individual needs ****Functional needs**** as related to ****Functional needs**** as related to

need to participate in mobility related need to participate in mobility related activities of daily livingactivities of daily living

Such as: personal hygiene; feeding; Such as: personal hygiene; feeding; dressing etc.dressing etc.

Remember these are not diagnosis driven Remember these are not diagnosis driven but ****functional needs**** driven.but ****functional needs**** driven.

Who is qualified to do the patient Who is qualified to do the patient evaluation & other statements evaluation & other statements

addressedaddressed CMS decision states this is beyond the scope of the CMS decision states this is beyond the scope of the

NCD (National Coverage Decision)NCD (National Coverage Decision)

Documentation issues are best addressed in an Documentation issues are best addressed in an initiative separate from this NCD due to the complexity initiative separate from this NCD due to the complexity of the issues.of the issues.

Outside the home: the primary purpose of DME is to Outside the home: the primary purpose of DME is to assist individuals in the home and “our regulations assist individuals in the home and “our regulations require that this equipment be appropriate for use in require that this equipment be appropriate for use in the home”the home”

Assessment will be a step wise from canes & walkers Assessment will be a step wise from canes & walkers through manual & power wheelchairs.through manual & power wheelchairs.

Other issues addressedOther issues addressed Local contractors would determine need for Local contractors would determine need for

multiple MAEs concurrently.multiple MAEs concurrently.

Non-compliance would also be a reason for Non-compliance would also be a reason for denialdenial

The environment must be assessed (verbally; The environment must be assessed (verbally; via phone or at delivery for Manual –physical via phone or at delivery for Manual –physical evaluation for Powerevaluation for Power

Canes, crutches, walkers fall along a continuum Canes, crutches, walkers fall along a continuum of technology so any discussion that did not of technology so any discussion that did not include them would be incompleteinclude them would be incomplete

Clinical Algorithm Clinical Algorithm What does this mean?What does this mean?

CMS has developed a “decision tree” to be CMS has developed a “decision tree” to be followed in deciding the appropriate equipment for followed in deciding the appropriate equipment for the beneficiaries individual needs as related to the beneficiaries individual needs as related to functional ADLs within the homefunctional ADLs within the home

This will make it easier for some areas but most This will make it easier for some areas but most Rehab providers have already developed this type Rehab providers have already developed this type of process & work well with referral sourcesof process & work well with referral sources

BE ALERT to all requirements –use documentation BE ALERT to all requirements –use documentation check off sheets available through your check off sheets available through your jurisdictions (D & Cs are comprehensive check jurisdictions (D & Cs are comprehensive check offs)offs)

Clinical CriteriaClinical CriteriaNOTE: NOTE: Date stamp documentation from physician Date stamp documentation from physician

effective effective {not accepting fax date at top of page due to multiple {not accepting fax date at top of page due to multiple

faxing}faxing}(power) 6/5/06(power) 6/5/06 Physician/ordering practitioner establishes that Physician/ordering practitioner establishes that

there is a mobility limitation – pt needs assistance there is a mobility limitation – pt needs assistance of some type of MAE- willingness to use! { A of some type of MAE- willingness to use! { A therapist evaluation DOES NOT negate need for therapist evaluation DOES NOT negate need for F2F by physician}F2F by physician}

Other conditions – cognition; judgment; vision – Other conditions – cognition; judgment; vision – completing adls within a reasonable time framecompleting adls within a reasonable time frame

NOTE _ when therapist involved it is a NOTE _ when therapist involved it is a combination of both that completes the F2F and combination of both that completes the F2F and

7 element order date would be date of 7 element order date would be date of “completion of” face to face – when physician “completion of” face to face – when physician reviews and signs off on clinical evaluation.reviews and signs off on clinical evaluation.

Other Limitations ExistOther Limitations Exist

If these exist can other provisions be made for If these exist can other provisions be made for use of equipment?use of equipment?

A – Caregiver (family member) available & who A – Caregiver (family member) available & who is willing and able to assist the beneficiary using is willing and able to assist the beneficiary using the w/cthe w/c

B - Compliance or non-compliance with use of B - Compliance or non-compliance with use of device (pt refuses to use can be grounds for device (pt refuses to use can be grounds for denial.denial.

Safety IssuesSafety Issues1.1. Has the beneficiary/caregiver demonstrated the Has the beneficiary/caregiver demonstrated the

capability & ***willingness*** to operate the MAE capability & ***willingness*** to operate the MAE safely?safely?

a.a. Risk to beneficiary and others must be addressed Risk to beneficiary and others must be addressed in safe use of itemin safe use of item

b.b. History of unsafe behavior?History of unsafe behavior?

c.c. Was there an actual trial of the equipment or Was there an actual trial of the equipment or follow up survey to make sure item provided was follow up survey to make sure item provided was appropriate & patient is able to use?appropriate & patient is able to use?

WOPD/Detailed Written WOPD/Detailed Written OrderOrder A supplier must have a verbal, faxed, or original order in their records before A supplier must have a verbal, faxed, or original order in their records before

they provide any item of durable medical equipment, prosthetics, orthotics they provide any item of durable medical equipment, prosthetics, orthotics and supplies to a beneficiary.and supplies to a beneficiary.

WOPD/ Detailed written order must contain: WOPD/ Detailed written order must contain: Patient’s name;Patient’s name; Description of the item (the description can be either a narrative or a brand Description of the item (the description can be either a narrative or a brand

name/model number) and the length of need.; name/model number) and the length of need.; If order is for accessories/supplies that will be provided on a periodic basis, it 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 must include appropriate information on the quantity used, frequency of change or use, and length of need.;change or use, and length of need.;

If order is for a drug, it must specify the name of the drug, concentration (if 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), dosage, frequency of administration, and duration of infusion (if applicable). ;applicable). ;

Patient’s diagnosis (policy applicable).; Patient’s diagnosis (policy applicable).; Expected start date of the order; Expected start date of the order; The physician’s signature and date.The physician’s signature and date. ***POWER (any type) must also include the actual date of F2F*** ***POWER (any type) must also include the actual date of F2F*** {7 element order}{7 element order}

DocumentationDocumentation

For any DMEPOS item to be covered by For any DMEPOS item to be covered by Medicare, the patient’s medical record must Medicare, the patient’s medical record must contain sufficient documentation of the contain sufficient documentation of the patient’s medical condition to substantiate patient’s medical condition to substantiate the necessity for the type & quantity of the necessity for the type & quantity of items ordered & for the frequency of use or items ordered & for the frequency of use or replacement (if applicable). ---- However, replacement (if applicable). ---- However, neither a physician’s order nor a CMN nor a neither a physician’s order nor a CMN nor a DIF nor a physician attestation statement by DIF nor a physician attestation statement by itself provides sufficient documentation of itself provides sufficient documentation of medical necessity, even though it is signed medical necessity, even though it is signed by the treating physician or supplier. ----” by the treating physician or supplier. ----”

Clinical Review JudgmentClinical Review JudgmentMM 6954 Effective 4/23/2010MM 6954 Effective 4/23/2010

1. 1. The synthesis of all submitted medial record The synthesis of all submitted medial record information (e.g. progress notes, diagnostic findings, information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient, andclinical picture of the patient, and

2. The application of this clinical picture to the review 2. The application of this clinical picture to the review criteria to determine whether the clinical requirements criteria to determine whether the clinical requirements in the relevant policy have been met.in the relevant policy have been met.

NOTE – Clinical review judgment does NOT replace poor or NOTE – Clinical review judgment does NOT replace poor or inadequate medical record documentation, nor is it a inadequate medical record documentation, nor is it a process that review contractors can use to override, process that review contractors can use to override, supersede or disregard a policy requirement (policies supersede or disregard a policy requirement (policies include laws, regulations, Centers for Medicare & include laws, regulations, Centers for Medicare & Medicaid (CMS) rulings, manual instructions, policy Medicaid (CMS) rulings, manual instructions, policy articles, national coverage decisions, and local coverage articles, national coverage decisions, and local coverage determinations.).determinations.).

Cane - WalkersCane - Walkers Can the functional Can the functional

deficit be resolved with deficit be resolved with use of a cane or use of a cane or walker?walker?

These should be These should be **appropriately** fitted **appropriately** fitted to the pt. for this to the pt. for this evaluation. evaluation.

Can the patient Can the patient “safely” use the cane “safely” use the cane or walker to complete or walker to complete MRADLs? MRADLs?

Gait instabilityGait instability

Environment AssessmentEnvironment Assessment

Can the beneficiary’s typical environment support Can the beneficiary’s typical environment support the use of w/c including scooters/POVs?the use of w/c including scooters/POVs?

Physical lay out; surfaces; & obstacles which would prevent Physical lay out; surfaces; & obstacles which would prevent use of the equipment in the home. Remember “in the home” use of the equipment in the home. Remember “in the home” is still there – If you need a bariatric chair for the bariatric is still there – If you need a bariatric chair for the bariatric patient will it fit in the home?patient will it fit in the home?

Will the patient be able to move around in the home with Will the patient be able to move around in the home with what ever item is provided & complete MRADLs?what ever item is provided & complete MRADLs?

Is there adequate access (ramps)Is there adequate access (ramps)

Manual vs PowerManual vs PowerUpper extremity functionsUpper extremity functions

What are limitations of What are limitations of strength, endurance, range of strength, endurance, range of motion, coordination or is there motion, coordination or is there absence of or deformity of one absence of or deformity of one or both UEs/or both UEs/

Upper extremity function would Upper extremity function would determine level of manual w/c determine level of manual w/c ie:lgt wgt vs standardie:lgt wgt vs standard

Is the surface area clear and are Is the surface area clear and are surfaces OK for manual w/c surfaces OK for manual w/c propulsion (rugs, clutter etc.)propulsion (rugs, clutter etc.)

Can pt. “safely” use the manual Can pt. “safely” use the manual w/c ***needs to be noted***w/c ***needs to be noted***

**If unable & there is a **If unable & there is a caregiver who is available, caregiver who is available, willing & able to provide willing & able to provide assistance a manual w/c may be assistance a manual w/c may be appropriate** DOCUMENTATION appropriate** DOCUMENTATION – is the key– is the key

Manual WheelchairsManual WheelchairsKX required on base and accessories 5/1/07KX required on base and accessories 5/1/07

KE {1/1/09} required accessories that could KE {1/1/09} required accessories that could be billed on round 1 competitive bid pmds.be billed on round 1 competitive bid pmds.

Categories:Categories: Capped Rental:K0001, K0002, K0003, Capped Rental:K0001, K0002, K0003,

K0004, K0006, K0007,E1031, E1038, E1039K0004, K0006, K0007,E1031, E1038, E1039 Inexpensive Routinely purchased: Inexpensive Routinely purchased:

K0005;E1161 E1231;E1233;E1234 (Rent K0005;E1161 E1231;E1233;E1234 (Rent /Purchase) {*ADMC} /Purchase) {*ADMC}

Other Wheelchair Base: K0009 {ADMC}* Other Wheelchair Base: K0009 {ADMC}* * Can go to ADMC but not required.* Can go to ADMC but not required.

MWCs codes to be MWCs codes to be revisedrevised

will be done by dmepdac no updates on thiswill be done by dmepdac no updates on thisKE modifier KE modifier required 1/1/09 for any accessory that could’ve been billed on a required 1/1/09 for any accessory that could’ve been billed on a

competitive bid pwc.competitive bid pwc. The practitioner caring for the patient orders the equipment.The practitioner caring for the patient orders the equipment. Practitioner can be : physician, licensed nurse practitioner, Practitioner can be : physician, licensed nurse practitioner,

clinical nurse specialist or physicians assistant.clinical nurse specialist or physicians assistant.

On a post pay audit the reviewer would expect to see:On a post pay audit the reviewer would expect to see: 1. Copy of order (if verbal will need a confirmation of 1. Copy of order (if verbal will need a confirmation of

verbal/phone order)verbal/phone order) 2. Detailed written order which is to be completed by supplier 2. Detailed written order which is to be completed by supplier

for physician/practitioner to review, sign & date (prior to bill on for physician/practitioner to review, sign & date (prior to bill on manual).manual).

3. Beneficiary Authorization3. Beneficiary Authorization 4. Proof of delivery4. Proof of delivery 5. Medical records which documents need5. Medical records which documents need

Bases (K0001 – K0002)Bases (K0001 – K0002)Although a F2F order is not required there still must Although a F2F order is not required there still must

be an ordering practitioner involved for ANY DME.be an ordering practitioner involved for ANY DME.

Standard manual K0001 would need diagnosis relating Standard manual K0001 would need diagnosis relating to inability to ambulate or use a cane or walker to inability to ambulate or use a cane or walker (basic information stating unable to use & why)(basic information stating unable to use & why)

Hemi – height K0002 would need the basic info as well Hemi – height K0002 would need the basic info as well as why a lower seat to floor height is required (for as why a lower seat to floor height is required (for foot propulsion or stand/pivot transfers) Height of foot propulsion or stand/pivot transfers) Height of patient – measurement of lower extremities need to patient – measurement of lower extremities need to be includedbe included

K0003 – K0004K0003 – K0004 K0003 (light weight manual) would need the basic K0003 (light weight manual) would need the basic

info plus documentation stating why a K0001 would info plus documentation stating why a K0001 would not meet needs and that the patient is able to self not meet needs and that the patient is able to self propel in base being provided.propel in base being provided.

K0004 (high strength light weight) basic info plus K0004 (high strength light weight) basic info plus why a K0001 – through K0003 would not meet why a K0001 – through K0003 would not meet needs. ( height/weight/ measurements ) what is needs. ( height/weight/ measurements ) what is available on the K0004 base that is not available on available on the K0004 base that is not available on lower level base. Patient activity level +(lower level base. Patient activity level +(in chair in chair >2hours/day)>2hours/day)

Functional needs – what exactly do they need to get Functional needs – what exactly do they need to get from point A to point B and complete their daily from point A to point B and complete their daily activities?activities?

K0005 (can go to ADMC)K0005 (can go to ADMC)

K0005 – Basic information plus – what is available on a K0005 – Basic information plus – what is available on a K0005 that is not available on a K0004. K0005 that is not available on a K0004. *** MUST be specific*** MAXIMAL (front to back) axle *** MUST be specific*** MAXIMAL (front to back) axle adjustability and why needed*** / or rigid base adjustability and why needed*** / or rigid base

Individual consideration only -- (can go to ADMC)Individual consideration only -- (can go to ADMC) ***Past use of same/similar equipment******Past use of same/similar equipment*** ADLs - specific to the individual and not broad or vague/ ADLs - specific to the individual and not broad or vague/

patient must be able to self propel in base being patient must be able to self propel in base being provided. {what do they do in this base that they can not provided. {what do they do in this base that they can not accomplish in a K-4} Not just basic axle adjustability accomplish in a K-4} Not just basic axle adjustability which some K0004s do have and not “just” a few pounds which some K0004s do have and not “just” a few pounds difference in weight difference in weight

WHY do they “NEED” this base to complete MRADLsWHY do they “NEED” this base to complete MRADLs NEED vs WANT NEED vs WANT

K0006 – K0007- K0009K0006 – K0007- K0009 K0006 – Heavy duty base – basic information plus weight K0006 – Heavy duty base – basic information plus weight

or diagnosis of acute spasticity or diagnosis of acute spasticity

Weight must be greater than 250 pounds weight can go in Weight must be greater than 250 pounds weight can go in narrative fieldnarrative field

K0007 extra heavy duty – weight greater than 300 pounds K0007 extra heavy duty – weight greater than 300 pounds plus basic infoplus basic info

K0009 – Individual consideration – name, make, model K0009 – Individual consideration – name, make, model and MSRP of base being provided and why a lower level and MSRP of base being provided and why a lower level base would not meet needs. Basic mobility information base would not meet needs. Basic mobility information required as wellrequired as well

Manual tilt (E1161 – E1231-E1234)Manual tilt (E1161 – E1231-E1234)Can go to ADMCCan go to ADMC

Manual tilt in space – E1161 (adult) E1231 –Manual tilt in space – E1161 (adult) E1231 –

E1234 (pediatric) – basic info for mobility E1234 (pediatric) – basic info for mobility first – PT/OT not required but best to do one first – PT/OT not required but best to do one (power tilt for manual tilt in space (K0108)(power tilt for manual tilt in space (K0108)

Why a standard base with reclining back will Why a standard base with reclining back will not meet needs – past history of same/similar not meet needs – past history of same/similar equipment – ADLS – caregiver assist -- being equipment – ADLS – caregiver assist -- being reviewed individually – F2F not required but reviewed individually – F2F not required but must show ordering practitioners’ involvement must show ordering practitioners’ involvement & PT/OT evaluation important. & PT/OT evaluation important.

Transporter Chairs {NO ADMC available}Transporter Chairs {NO ADMC available} E1038 /E1039(HD)– transporter chair or E1031 E1038 /E1039(HD)– transporter chair or E1031

(roll about chair) To be provided “in lieu of” a (roll about chair) To be provided “in lieu of” a standard w/c so need basic information relating standard w/c so need basic information relating to need for a w/c for mobility and not just to need for a w/c for mobility and not just needed for “outside the home”needed for “outside the home”

POVs-ASSESSMENTPOVs-ASSESSMENT

Basically rules are the sameBasically rules are the same Does pt. have strength & postural Does pt. have strength & postural

stability to operate?stability to operate? Is there adequate access (space) “in Is there adequate access (space) “in

the home”the home” Does the pt. have the ability to safely Does the pt. have the ability to safely

operate the POVoperate the POV F2F & Home eval requiredF2F & Home eval required

Timelines & Dates MAETimelines & 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 2011Page 2 revisions 2011February 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?Who can order?

The practitioner caring for the patient The practitioner caring for the patient orders the equipment.orders the equipment.

Practitioner can be : physician, licensed Practitioner can be : physician, licensed nurse practitioner, clinical nurse nurse practitioner, clinical nurse specialist or physicians assistant.specialist or physicians assistant.

The ordering practitioner must have The ordering practitioner must have their own UPIN number. (NPI-May- 2007)their own UPIN number. (NPI-May- 2007)

The physician does not have to review The physician does not have to review and sign behind the LNP; PA or CNSand sign behind the LNP; PA or CNS

When did this start?When did this start? May 5, 2005 MAE was published by CMS - effective May 5, 2005 MAE was published by CMS - effective

07/05/2005 07/05/2005 8/24/2005 CMS issued no CMNs for PMDs8/24/2005 CMS issued no CMNs for PMDs 9/14/2005 – Evidence of Medical Necessity was issued relating 9/14/2005 – Evidence of Medical Necessity was issued relating

to PMDsto PMDs ***9/23/2005*** No CMNs for Manual w/cs ***9/23/2005*** No CMNs for Manual w/cs 10/01/2005 – Transitional CMNs required10/01/2005 – Transitional CMNs required 3/10/2006 – Memo from CMS – Claims to be paid based on 3/10/2006 – Memo from CMS – Claims to be paid based on

current policy (ie: RX does not have to contain the 7 elements current policy (ie: RX does not have to contain the 7 elements & the information does not have to be to the supplier in 30 & the information does not have to be to the supplier in 30 day time frame)day time frame)

4/1/2006 – 30d changed to 45 d effective 06/05/2006/ date 4/1/2006 – 30d changed to 45 d effective 06/05/2006/ date stamp/equal required on documentation from physician stamp/equal required on documentation from physician (power)(power)

7/11/06 – 120d to deliver chair effective 8/10/06(power)7/11/06 – 120d to deliver chair effective 8/10/06(power) 7/11/06 -Attestation statement from supplier that there is no 7/11/06 -Attestation statement from supplier that there is no

financial relationship with PT/OT doing eval- 8/10/06(date of financial relationship with PT/OT doing eval- 8/10/06(date of bill driven) – detailed written order needs to include: brief bill driven) – detailed written order needs to include: brief description of item ; HCPCs code your charge-Medicare description of item ; HCPCs code your charge-Medicare allowable prior to delivery (on/after 8/24/06) (power)allowable prior to delivery (on/after 8/24/06) (power)

May 1, 2007 – KX modifier required for all manual w/cs and May 1, 2007 – KX modifier required for all manual w/cs and accessoriesaccessories

2008 (coding for manual wheelchairs to be revised) watch 2008 (coding for manual wheelchairs to be revised) watch VGM discussion board & your list serve from the DME MACsVGM discussion board & your list serve from the DME MACs

October 2009 DPT required for base and all accessories October 2009 DPT required for base and all accessories

CMNS as processing toolsCMNS as processing tools Electronic payment of claims was guided by the answers on the Electronic payment of claims was guided by the answers on the

CMN, we as suppliers had a false sense of security, because we CMN, we as suppliers had a false sense of security, because we felt if the CMN was completed correctly we were covered on a felt if the CMN was completed correctly we were covered on a post pay audit.post pay audit.

The fact is that each DMERC/DME MAC was & is required by law to The fact is that each DMERC/DME MAC was & is required by law to audit for improper use of CMNs.audit for improper use of CMNs.

The old pay and chase game. The old pay and chase game.

Some took advantage of this system so we get the “boot” end of Some took advantage of this system so we get the “boot” end of the reaction to the fraud and abuse (mistakes???? etc) *******the reaction to the fraud and abuse (mistakes???? etc) *******

Basically --The Medical Necessity information required needs to Basically --The Medical Necessity information required needs to be in the patients medical file (Physicians be in the patients medical file (Physicians progress notes -SNF-progress notes -SNF-Hospital-PT/OT-home health) etc. Hospital-PT/OT-home health) etc.

NO SUPPLIER GENERATED “PHYSICIAN FORMS” OK for blank 7 NO SUPPLIER GENERATED “PHYSICIAN FORMS” OK for blank 7 element order --element order --

Manual W/Cs – Audit Requests Manual W/Cs – Audit Requests On post pay –reviewers may expect to see:On post pay –reviewers may expect to see:

1. Copy of order (if verbal will need a 1. Copy of order (if verbal will need a confirmation of verbal/phone order)confirmation of verbal/phone order)

2. Detailed written order which is to be completed 2. Detailed written order which is to be completed by by supplier for physician/practitioner to review, supplier for physician/practitioner to review, sign & sign & date (prior to bill on manual).date (prior to bill on manual).

3. Beneficiary Authorization3. Beneficiary Authorization 4. Proof of delivery4. Proof of delivery 5. Medical records which documents need.5. Medical records which documents need. 6. Proof patient is able to use chair safely & it is 6. Proof patient is able to use chair safely & it is

able to able to be used through out their be used through out their environment.environment.

Medical Records – what are Medical Records – what are they?they?

Medical records can consist of:Medical records can consist of: Physicians/practitioners’ progress notesPhysicians/practitioners’ progress notes Nursing home discharge summaryNursing home discharge summary Hospital discharge summaryHospital discharge summary Home health notesHome health notes Any clinicians’ notes or evaluations Any clinicians’ notes or evaluations

(PT/OT) etc.(PT/OT) etc.

What are they expecting to What are they expecting to see?see?

Documentation relating to the impairment of Documentation relating to the impairment of mobility which could be in the form of a history mobility which could be in the form of a history and physical, follow up notes relating to disease and physical, follow up notes relating to disease progression, surgery notes stating date of progression, surgery notes stating date of surgery, outcome of treatments tried and failed --surgery, outcome of treatments tried and failed --

Documentation as to why a cane or walker would Documentation as to why a cane or walker would not meet the functional needs of the patient. not meet the functional needs of the patient.

Sometimes just the diagnosis would relate to this Sometimes just the diagnosis would relate to this but if in doubt request a PT/OT eval. but if in doubt request a PT/OT eval.

Diagnosis such as gait instability / frequent falls Diagnosis such as gait instability / frequent falls /frail individual which would also need /frail individual which would also need explanation of need for specific base.explanation of need for specific base.

OH – NO-- where do I get OH – NO-- where do I get this?this? Some of the information for basic manual Some of the information for basic manual

wheelchairs will come from your own wheelchairs will come from your own “environmental” evaluation or PT/OT notes “environmental” evaluation or PT/OT notes which would require ordering practitioner to which would require ordering practitioner to review and sign off on.review and sign off on.

Each manual base will require something Each manual base will require something stating why the lower level base would not stating why the lower level base would not meet needs.meet needs.

The clinical notes from a clinical area will The clinical notes from a clinical area will drive payment – Home health; discharge H drive payment – Home health; discharge H & Ps (summaries) form SNFs/ICFs/ & Ps (summaries) form SNFs/ICFs/ Hospitals / Rehab hospitals etc.Hospitals / Rehab hospitals etc.

AccessoriesAccessoriesAll additional accessories that were formally place in part C of All additional accessories that were formally place in part C of

the CMN will require a detailed written order including the CMN will require a detailed written order including codes codes

Needs to state the base/ HCPCs code brief description – your Needs to state the base/ HCPCs code brief description – your charge and Medicare allowable that has been reviewed by charge and Medicare allowable that has been reviewed by the physician/ordering practitioner, signed and dated.the physician/ordering practitioner, signed and dated.

A lot of the manual bases can be explained with diagnosis A lot of the manual bases can be explained with diagnosis alone (stroke/bi-lateral amputee etc) but look for discharge alone (stroke/bi-lateral amputee etc) but look for discharge summaries from hospital/SNF/Rehab facilities for additional summaries from hospital/SNF/Rehab facilities for additional information.information.

Mobility is specific to functional MRADLS & not just diagnosis Mobility is specific to functional MRADLS & not just diagnosis driven so watch the cardiopulmonary diagnosis since these driven so watch the cardiopulmonary diagnosis since these sometimes require specific documentation relating to the sometimes require specific documentation relating to the ADLS and caregiver assistance. ADLS and caregiver assistance.

KX -- required on base and all accessories KX -- required on base and all accessories 5/5/07 5/5/07

KE -- req. all accessories that could be billed on cb KE -- req. all accessories that could be billed on cb pwcs. (1/1/09)pwcs. (1/1/09)

““Fit the patient to the chair and not the chair to the Fit the patient to the chair and not the chair to the

patient”patient”