Power wheelchairs and scooters are a favorite target of Durable Medical Equipment Regional Carrier (DMERC) auditors, and recently the pace of DMERC audits has picked up. Because these items are costly and desired by beneficiaries, power operated vehicles (POVs in Medicare parlance) must meet stringent requirements for documentation for medical necessity.

This means that providers of mobility equipment face some difficult choices. If they insist that physicians provide them with medical necessity documentation that will meet Medicare standards, they risk losing sales and alienating referral sources. If they do not, they risk denials and overpayment determinations.

The problem is particularly acute for suppliers who deal exclusively in power mobility products and market directly to patients. Though it may be challenging to obtain documentation at the time of the order, trying to collect that same documentation for a DMERC audit months after the sale is much more difficult.

To avoid problems, review each Certificate of Medical Necessity (CMN) carefully when you receive it. Is section B completed in full by the physician, by an employee of the physician’s practice, or by another clinician involved in the patient’s care? Completion of Section B should include provision of appropriate ICD-9 diagnosis codes supporting the need for the chair and for any accessories ordered.

Next check if Section D of the CMN was signed and dated in the physician’s handwriting. If Section B was completed by someone other than the physician, that person must sign Section B and identify his or her employer. Any changes or corrections to Section B must be initialed and dated by the physician.

You should also ask that the physician’s office provide supporting documentation from the patient’s medical record. If the documentation in the physician’s records does not substantiate medical necessity according to the coverage criteria in the relevant DMERC medical policy and the physician is unable or unwilling to supply additional documentation, you have several choices. One option is to ask the patient to sign an Advance Beneficiary Notice (ABN) form. This document says the patient understands that Medicare may deny coverage because of lack of medical necessity and that the patient will be responsible for the cost of the wheelchair or scooter if Medicare denies the claim. Another option is to obtain a professional wheelchair evaluation. Policies on wheelchair evaluations paid for by suppliers vary among the DMERCs. In Region B, a supplier may pay for a wheelchair evaluation if a licensed or certified physical therapist or occupational therapist performs the evaluation. Region C’s policy is that the DMERC may consider a wheelchair evaluation paid for by the supplier, but it will consider an independent evaluation more seriously. A final option is to deliver the wheelchair or scooter based on the documentation provided and hope for the best in the event of an audit. However, providers who routinely choose this course are at risk for the entire cost of the scooter or wheelchair if an auditor determines that the item provided was medically unnecessary.

What to Do, When They Come For You
Any provider that submits a significant number of claims to the Medicare program for POVs is likely to be audited at some point. What should you do when your turn comes?

First, be sure you understand the scope of the audit and your potential exposure. If the audit request covers only a small number of claims and all of the dates of service are within a short period, then your immediate exposure is probably limited to possible repayment of some or all of those claims. But if the audit covers a random sample of claims over a longer period of several months to several years, the stakes are higher.

Medicare rules allow a carrier to audit a statistically valid random sample of claims in a given time period and extrapolate the results of that audit to all the claims filed during the period covered by the audit. In other words, your DMERC may audit 30 claims selected at random from all your power wheelchair claims in a year, and if it finds insufficient documentation of medical necessity in 15 out of the 30 files, it can assess an overpayment equal to 50% of all your power chair claims that year. So a random sample audit puts all of your Medicare power chair revenue for the audit period at risk. If you are faced with such a random sample audit (sometimes referred to as a RAT STAT audit, after the statistical software package used to perform the audit), consider engaging a consultant or legal counsel to assist you.

Your Right To Appeal
Any power wheelchair or scooter provider who receives an audit letter should understand that it is highly likely that the audit will result in denial of some of the claims, no matter how good the provider believes his or her documentation is. However, it may be possible to have many of those denials reversed at a carrier hearing by collecting and submitting additional medical necessity documentation.
In an appeal from an overpayment determination, the carrier hearing officer considers not only the documentation submitted for the audit, but also any supplemental documentation that the supplier provides before the hearing. If an overpayment determination is based on an extrapolated random sample audit, every denial that is reversed on appeal could translate into a reduction of thousands of dollars in the total amount of the overpayment.

With that in mind, you or your legal counsel should conduct a thorough, critical review of the documents to be provided in response to the audit request. Identify those files that have potential documentation deficiencies and collect supplemental documentation to improve the chances of avoiding a denial or having those denials reversed on appeal.

If it is impossible to obtain physician progress notes from the time the POV was ordered, ask the physician to supply a letter explaining the medical necessity of the power wheelchair or scooter, with reference to the specific coverage criteria in the medical policies. You should not write the letter for the physician, but you may quote specific language from the coverage policy to inform the physician of the criteria that should be addressed in the letter.

All supplemental documentation should be dated as of the day it is actually completed. Never backdate orders, progress notes, or other documentation. Although contemporaneous documentation is ideal, documentation of the patient’s condition at the time the wheelchair or scooter was ordered may be considered by a hearing officer even if it is prepared later.

Cutting Your Losses
There are a few documentation deficiencies that cannot be corrected after the fact. For example, a low-pressure positioning seat pad, Healthcare Common Procedure Coding System code E0192, requires a written order prior to delivery. If your file does not include a written physician’s order dated prior to the day of delivery of the seat pad, you should not try to correct the problem. Instead simply accept the denial.

Mobility providers who have not been through a DMERC audit often tend to be complacent about documentation. That changes once they have been through the audit and appeal process. If you are lucky enough not to have been audited yet, you can save yourself and your company both money and stress by focusing on tightening up documentation procedures now.

Tim Webster, JD, is an attorney with the Health Care Group of Brown & Fortunato, PC, Amarillo, Tex. He can be reached at (806) 345-6347; twebster@bf-law.com.