Mobility assistive equipment (MAE) coverage criteria seem to be filled with dangerous obstacles and unanswered questions. As an industry, we have grumbled about certificates of medical necessity (CMNs) and misleading questions for years, but we accepted the change and have continued to provide quality patient care. Now, with CMNs gone and coverage criteria up for interpretation, we have panic and chaos because patient care is in question if you cannot provide services that you know will be reimbursed. For the majority of providers, patients are the top priority—but you still must get paid.

At this point, there is little anyone can say that will give you a warm fuzzy feeling. However, we can hope for the best and prepare for the worst—which seems to be a common theme of late.

Face to Face
First of all, physicians must conduct face-to-face examinations with patients 30 days prior to ordering power mobility equipment. The equipment being set up must be documented in physician chart notes. Physicians can bill for an additional procedure code to the standard office visit, which will result in an additional reimbursement of approximately $23.

There should be documentation in the medical records of the physician, hospital, rehabilitation facility, home health company, or physical therapist that indicates the onset of the condition and the deterioration of the condition that warrants the need for the equipment and accessories, regardless of the primary equipment type. Likewise, there should be documentation as to why a lesser piece of equipment could not be used such as a walker or manual wheelchair.

Physical therapy notes are generally going to be the most detailed when it comes to strengths and weaknesses of different equipment types. The notes must include height and weight, upper and lower extremity strength, weakness, limitations, capabilities, range of motion, and diagnosis. Remember, the equipment may not be specifically diagnosis driven, but more than diagnosis codes may be required to paint a complete picture of the patient’s physical limitations and needs for the equipment. The assessment must be independent of the supplier. This means the supplier cannot pay for the physical therapist/occupational therapist assessment.

Now, a current physical evaluation of the patient will be needed within 30 days prior to the setup to conclude the order for the equipment. The face to face and physical evaluation may be on the same day so long as both are within the 30 days prior to setup.

The physician must also document the order for the equipment in his chart notes—along with the order for the evaluation and the review and agreement with the evaluation. If it is not in writing, the theory is that it did not happen. Therefore, it is extremely important to have clear, concise chart notes. You might consider a checklist of all the areas of documentation Medicare wants for review.

The supplier must gather all this documentation to submit the claim. I strongly recommend that you obtain all the documentation prior to providing the equipment to the patient.

Providers must complete a home assessment, which should be done for all equipment, not just mobility, to determine if it will fit in the home and can be used safely. If patients pick up the equipment at the storefront, review the home assessment form and have them sign it. Based on conversations I have had with DMERC representatives, suppliers do not have to go to homes when patients pick up equipment.

The only way to be successful with these requirements is to educate staff members and referral sources on what Medicare expects. This may be in coverage criteria or on pre- and post-payment audits. Staff members must ask for the documentation up front at the time of the order. They need to ask if the patient has been seen and on what date.

Knowledge Is Power
Staff members should know immediately if patients need to request another face-to-face examination. Someone in your organization needs to be the point person to review and read all documentation to ensure ambulatory ability is clearly and adequately discussed for people who may not know or see the patient. This point person will also need to look for conflicting information such as “patient walks around the house or to the mailbox” and “patient is legally blind” or other comments that would generate questions. Such questions could be: If the person can walk around the house, why do they need a power wheelchair? Or if the patient is legally blind, how can they see to safely operate the equipment?

Now, you can be legally blind and still see enough to be self-sufficient, but that extra documentation is needed to justify the equipment. The point person in your organization should be the one to give the approval to proceed with the order—because if you put the equipment out, you want a high degree of certainly that you will be paid. Remember, you cannot obtain advance beneficiary notices (ABNs) on every single patient, so you need to be able to document those cases that are questionable and have the patient sign an ABN prior to or at the time of delivery, so you have a means of collecting reimbursement.

To help educate referral sources, the DMERCs have a five-page letter to physicians explaining recent changes. You should print that document and make copies for physicians. You might even consider getting several of your physicians together for a presentation. All these precautions can help you charter a safe course on a seemingly chaotic path. DP

Angela Miller is president and CEO of Medical Auditing Solutions LLC, Lewisville, Tex. She can be reached via e-mail: info@medicalauditingsolutions.com.