Imagine you get the call from a Mrs Jones. She is a 75-year-old Medicare beneficiary with COPD, coronary artery disease, and severe arthritis. She wants a power mobility device (PMD) that she has seen on television. In the past, all you technically needed as a provider was a properly completed certificate of medical necessity (CMN) signed by a treating physician, and a prescription. However, CMS has issued new Local Coverage Determinations (LCDs) for PMDs that are different from previous coverage.

Three years ago, Dealer Provider gave us the opportunity to write about best practices in the provision of wheeled mobility and seating devices called "Raising the Bar" (see the February 2003 issue in the www.hhcdealer.com archives). In 2003, we had not established consistent best-practice guidelines, and we were witnessing widespread growth in the K0011 power wheelchair benefit under Medicare. Soon thereafter, mainstream media stories portrayed examples of Medicare fraud and abuse by physicians and suppliers, which led to "Operation Wheeler-Dealer" (OWD) by CMS.

Mark R. Schmeler, PhD, OTR/L, ATP

OWD was nothing more than a reclarification of the outdated coverage policy, but it did not mirror modern standards of practice for the treatment and accommodation of people with disabilities. Fortunately, federal agencies recognized the need to reexamine and update the coverage policies after a strong grassroots lobby. Thus, over the past two and a half years, our industry has experienced more new Interim Final Rules (IFRs) and National and Local Coverage Determinations than our most seasoned policy experts can follow. Fortunately though, these new policies are closer to acceptable practice guidelines than previous policies. Although the Budget Reconciliation Act passed in late December defers CMS from implementing the IFR that eliminates the certificate of medical necessity (CMN)--and replaces it with clinical documentation--it has been recommended that all parties use LCD criteria in anticipation of an IFR.

If you work closely with other practitioners in the health care continuum, you need strategies for implementing these new policies. We understand that most Dealer readers are providers and that under the new policies, documentation of need is the responsibility of treating physicians or occupational and physical therapists. However, most physicians and therapists are not aware of the intricate policies and documentation requirements for mobility assistive equipment. Therefore, in many cases, it will be up to you to point clinicians to resources (such as this article).

In October 2005, the DMERC Medical Directors issued a letter to physicians outlining the new coverage policies for PWCs and POVs. The letter informs physicians that they should address the following questions when performing their assessment of potential PMD candidates and preparing clinical documentation:

• What is this patient?s mobility limitation and how does it interfere with the performance of activities of daily living?
• Why can't a cane or walker meet this patient's mobility needs in the home?
• Why can't a manual wheelchair meet this patient's mobility needs in the home?
• For a POV, does this patient have the physical and mental abilities to transfer into a POV and to operate it safely in the home?
• For a PWC, why can't a POV meet this patient?s mobility needs in the home?
• For a PWC, does this patient have the physical and mental abilities to operate a PWC safely in the home?

The LCDs for both POVs and PWCs provide more specific coverage qualifiers such as: the patient has a mobility limitation that significantly impairs their ability to participate in one or more MRADLs such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home.

Back to Mrs Jones
To respond appropriately to your call from Mrs Jones, ask her if she has seen a treating physician and whether she has discussed the use of a PMD as a reasonable alternative to address her mobility needs. If she has not, refer her back to her physician in the same manner a pharmacist discussing drug interventions would do. Contact the physician and advise them of your contact with the patient, the Medicare coverage criteria, and what documentation they must provide if they feel a PMD is appropriate.

If the physician feels it is appropriate, remind them that it is within the scope of practice to refer to a therapist to provide a portion of the face-to-face assessment findings and documentation related to the most appropriate MAE intervention. A general practice physician can also refer patients to a physiatrist who has expertise in rehabilitation.

If not already done, providers should find therapists who can perform MAE assessments and fully educate physicians on applicable policies. Know that under the new policies providers cannot pay clinicians to perform MAE assessments. This is to prevent bias in recommendations. Physicians as well as occupational and physical therapists, however, can bill third-party insurances—including Medicare—for their services.

Does Mrs Jones Need Power Mobility?
Using the case example of Mrs Jones and criteria provided in the DMERC letter to physicians, we can illustrate proper documentation of need. The DMERC letter carefully states that these criteria are examples of what might be included in the documentation, but says all criteria are not necessary in every case. It is up to the physician to determine what is appropriate and pertinent for each case. Therefore, this case may provide more detail than what is necessary.

Documentation Should Include
• Symptoms
• Related diagnoses
• History
• How long the condition has been present
• Clinical progression

Mrs Jones is seen for a face-to-face assessment because she is experiencing increased difficulty with functional mobility that severely limits her ability to perform ADLs. She is 75 years old with a medical history of COPD (oxygen dependent since 2004), myocardial infarctions in 2001 and 2004, as well as severe chronic osteoarthritis of the hips, knees, and shoulders. Due to the underlying nature of her conditions and the fact that she is aging, her situation is progressing with a guarded prognosis over the next few years.

Interventions Tried with Results
• Walker
• Manual wheelchair
• POV or power wheelchair

She has been to physical therapy to work on improving ambulation. However, the outcome has been marginal. Because of her cardiopulmonary status, she is not a candidate for surgical interventions. She has been using a four-wheeled walker for the last 2 years, but this is becoming difficult due to her need to transport oxygen equipment.

She is falling about two times a month, and a recent fall resulted in a laceration to her forehead that required a visit to the emergency department. Falls may be life-threatening since she is on anticoagulation medication.

She received a manual wheelchair from a family member but depends on others to push her since her shoulder arthritis, cardiac history, and shortness of breath prevent self-propulsion. She has tried both a power wheelchair and scooter during an assessment by the therapist and demonstrated the ability and willingness to operate these devices safely and effectively.

Check These Additional Factors
• Strength
• Range of motion
• Sensation and coordination in the arms and legs.
• Tone and/or deformity of arms, legs, or trunk.
• Neck, trunk, and pelvic posture
• Flexibility
• Sitting and standing balance

A therapist’s evaluation and physician examination showed active shoulder flexion/abduction to approximately 90 degrees with 3/5 shoulder strength—and pain, crepitations, and shortness of breath were noted. She has full active range of motion in the elbows, wrists, and hands with 4/5 strength; however, there is fatigue and shortness of breath on testing. Active range of motion is within functional limits throughout the lower limbs with 4/5 strength and crepitations in the knees and shortness of breath.

Sensation is intact throughout for light touch and pin prick. Tone is normal throughout. She has good sitting balance with a symmetric trunk and pelvis as well as full cervical range of motion. She can stand only for a few minutes before she develops pain throughout her lower limbs, becomes short of breath, and loses her balance.

Check for problems transferring between a bed, chair, and PMD. Can the patient successfully walk around the home? In answering these questions, provide information on distance walked, speed, and balance.

In the therapist’s evaluation report, Mrs Jones demonstrated the ability to perform a stand-pivot transfer from a PMD to another surface with the use of her walker, but did struggle and depended heavily on the armrest to rise from a lower seated position. She is able to dress herself from a seated position with increased time, using energy conservation techniques.

She requires someone to retrieve her clothing from the closet and drawers and to set them up for her due to her limited mobility. She can bathe herself using a bath transfer bench, grab bars, and a handheld shower nozzle, but requires supervision and assistance getting into the bathroom due to her limited ability to ambulate. She can feed herself but depends on others for meal preparation due to her limited ability to stand and move throughout the kitchen. Her ambulation was slow and unsteady with significant risk for falls when she walked less than 10 feet in the clinic.

To determine whether a certain PMD is appropriate and will maneuver in the home, the LCD states that it is the responsibility of providers to keep documentation related to home accessibility. It is important for providers to do a full home assessment, but the physician may also order a separate home evaluation by a therapist to obtain more information.

What documentation Should You give to thephysician and therapist?
For Mrs Jones, the process continued with a home visit from an ATS. Jones lives alone in a one-story home with an accessible entrance through the garage. Her bedroom, bathroom, kitchen, and living area are on one level. Upon inspection and measurement, it was apparent that a scooter would not maneuver in the tight confines of the home. Her daughter was present for the visit and assisted Mrs Jones with a stand-pivot transfer to a PWC. She was able to maneuver the properly fitted PWC throughout all areas of the home in a safe and effective manner, including the narrow doorway into her bathroom.

After these assessment findings are described, documentation should then lead to why a certain PMD was chosen over other lower cost alternatives. Based on the assessment of Mrs Jones’ needs, the physician and therapist determined that a mid-wheel-drive PWC with a standard captain’s style seating system was the most reasonable and cost-effective alternative to meet her needs.

Justification for PMD
• Ambulation is not within her medical best interest even with the use of a walker due to severe osteoarthritis of the hips and knees, pain, shortness of breath, and poor balance with a history of falls.
• She is unable to propel any type of manual wheelchair due to severe osteoarthritis of the shoulders and shortness of breath associated with her COPD and cardiac history.
• She is not a candidate for a scooter as a scooter will not maneuver in the confines of her home per report of a home assessment by the supplier.
• A mid-wheel-drive power wheelchair is the only reasonable alternative.
• Jones is motivated to use the device in her home to engage in meaningful MRADLs safely and effectively, specifically to get to her bedroom for dressing, retrieving clothes from the closet, getting to the bathroom for bathing and toileting, and preparing light meals in the kitchen.
• Without the power wheelchair, she will be more dependent on others to assist her and be at significant risk for further falls resulting in costly medical interventions.

After appropriate need and documentation are established, it is the responsibility of everyone involved, including the supplier, to respond to client concerns and equipment problems after delivery. DP

Mark R. Schmeler, PhD, OTR/L, ATP, is a faculty member of the Department of Rehabilitation Sciences at the University of Pittsburgh (UP). He recently stepped down as director of the Center for Assistive Technology at the UP Medical Center to pursue related interests that include expansion of wheeled mobility and seating service into rural areas via telerehabilitation consultation and continuing education venues for the industry. He can be reached via e-mail: schmeler@pitt.edu.

Brad E. Dicianno, MD, is a physician in the Department of Physical Medicine & Rehabilitation at the University of Pittsburgh Medical Center in the spina bifida outpatient clinic, and the Center for Assistive Technology.

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