Mastering new Medicare mobility documentation changes is critical to minimizing rejected claims, improving audit outcomes, and maintaining a smooth rehab business.

Riveting evidence of fraud and abuse by a minority of physicians and suppliers has cost the government and taxpayers plenty and resulted in a total overhaul of CMS’ coverage decisions regarding mobility products. Even with all that, we did not envision a year of ongoing changes such as the one we have had.

There was a time when “post-pay audit” was synonymous with a provider receiving a letter from a DMERC asking for proof of delivery and a copy of the signed and dated certificate of medical necessity (CMN). The response was fairly simple—send copies of the delivery receipt, the initial order, and the CMN. If the documents were completed comprehensively and correctly, the supplier retained his payment.

With the release of the National Coverage Decision (NCD) for all mobility devices (effective May 5, 2005) and the Interim Final Rule (IFR) for power mobility devices (effective October 25, 2005), required documentation has become a focal point. Several updates have followed, replacing previously introduced requirements with more specific ones. As of November 15, 2006, the new local coverage decision (LCD) for power mobility devices spells out—in detail—coverage rules, documentation mandates, and new health care procedure codes (HCPCS). The role of the supplier has always been an important one in the realm of health care for patients at home, but never before has the supplier been so accountable in so many ways.

New Documentation Requirements for manual mobility
• Long overdue “bed/chair confinement” coverage criteria have been replaced by documentation of the patient’s functional level. The medical record must identify one or more MRADL that are impaired by the patient’s mobility limitation. CMS lists five activities as examples of an MRADL: toileting, feeding, grooming, dressing, and bathing. CMS stipulates that these are only examples and not a comprehensive list.

• To assure the correct level of MAE is ordered, CMS designed a clinical algorithm with nine questions that must be addressed in the medical record. This algorithm guides the clinician to document a patient’s functional level by negating one or more lower end products that the patient is unable to use, unable to use safely, or unable to use in an appropriate time to achieve the MRADL listed. The algorithm’s lowest level of equipment is a cane and culminates with a power wheelchair. To qualify for a power chair, the medical record must illustrate why a patient cannot use any level of manual mobility or a POV/scooter.

• The CMN has been totally removed from the equation and replaced by the medical record. The medical record is a comprehensive summary of patient symptoms, related diagnoses and conditions, medical history, physical examination, functional assessment (if done by other than the MD or practitioner), test results, discharge summary, OT notes, PT notes, and home health record notes. Patient records will differ depending on the severity of the disability and the MAE ordered. The medical record is always requested for prepay and postpay audits.

• An order is required—formatted according to guidance in the program integrity manual (PIM). It must be signed and dated prior to billing.

PMDs as of November 15, 2006
• A face-to-face exam by the treating physician or practitioner must be conducted prior to writing an order, which must be formatted with the beneficiary name, date of face-to-face exam, pertinent diagnoses/conditions that relate to PMD need, length of need, physician or practitioner signature, and date of signature.

• The medical record must clearly indicate that a major reason for the face-to-face examination was a mobility evaluation in a detailed narrative note in the chart. A supplier-created format to document this information is NOT a substitute for a comprehensive chart note.

• The initial order and patient medical record documentation must be forwarded to the supplier within 45 days of the face-to-face exam.

• If the patient is sent for a functional evaluation by an LCMP within 45 days of the date the physician or practitioner signs and dates his concurrence or disagreement with the report and developed specifications, the document must be forwarded to the supplier. If the physician physically examined the patient prior to sending the patient for a functional evaluation, he does not have to re-examine the patient. However, if the physician or practitioner did not conduct a face-to-face examination prior to the functional evaluation, he must meet with the patient after he receives the report and prior to sending all information to a supplier.

• If the patient receives his face-to-face examination as an inpatient, the order and patient information must be forwarded to the supplier within 45 days of discharge.

As of October 1, 2006, the new local coverage decision (LCD) for power mobility devices spells out—in detail—coverage rules, documentation mandates, and new health care procedure codes.

• A supplier MUST be able to prove receipt of the medical information was within 45 days of the face-to-face examination, through either date/stamping documents or fax machine automatic dating.

• An LCMP who performs a functional evaluation may not have a financial relationship with the supplier. An attestation to this must be on file, signed by the supplier. The only exception to this rule is if the supplier is owned by a hospital and the OT or PT works in the inpatient or outpatient hospital setting.

Check out the December 2006 issue for part II of Mobility Documentation: What You Need to Know.

Georgie Blackburn is president of the Pennsylvania Association of Medical Suppliers (PAMS) and compliance director/privacy officer for BLACKBURN’S Physicians Pharmacy, Tarentum, Pa. She is rehab team leader for the Region A Advisory Council and reachable via e-mail: georgie.blackburn@blackburnsmed.com.