For claims with dates of service of April 1, 2008: For a Group 2 single power option or multiple power option power wheelchair, any Group 3 or Group 4 power wheelchair, or a push rim-activated power assist device for a manual wheelchair:

•   A specialty evaluation by a RESNA-certified assistive technology provider (ATP) specializing in wheelchairs or a physician who is board-certified in physical medicine and rehabilitation is required.

•   The PMD must be provided by a supplier who employs a RESNA-certified assistive technology supplier (ATS) specializing in wheelchairs, who is directly involved in the wheelchair selection for the patient.

WE ARE THE EDUCATOR

CMS released its decision and the program safeguard contractors (PSCs) released the local coverage determinations (LCDs) to enforce requirements. CMS has recommended that suppliers educate referral sources. To assist us, the PSCs released two guidance bulletins in October 2005 and August 2006, designed for all health care practitioners and managerial members of the physician/supplier staff.

HERE IS WHERE IT GETS TRICKY

Suppliers well remember how, not too long ago, physicians failed to read completion requirements for wheelchair CMNs, resulting in multiple remailings, sometimes as many as three or four times! Even with legal cover letters detailing exactly what to address in Section B and Section D, time after time, forms were returned with incomplete or incorrect completion. It stalled our billing processes and greatly impacted our receivables. Physicians and their staffs became agitated by the mounds of paperwork they received and voiced their disagreement with having to complete them.

Now that the medical record has replaced the CMN, how do we effectively convey all of the new requirements without aggravating those who prescribe? When do we educate referrals? How do we educate referrals? Where should suppliers start? It is a dilemma.

Suppliers must first fully train internal staff prior to training referral sources. Savvy suppliers have developed in-services, seminars, and educational materials for inside and outside personnel. They are educating referrals through their sales, marketing, and compliance staff—and this demands a major time and financial commitment.

Other firms have depended solely on manufacturers and other associations to provide pertinent guidance and materials. However, the PSC medical directors have warned that the latter may be risky because information from alternative sources is not always correct, and guidance will not suffice in an audit.

There is a vast difference in financial resources that national, regional, and small suppliers can commit to the educational curve. Differently sized companies do not and cannot operate in the same manner. Suppliers are perplexed, frustrated, and sending inconsistent messages to the referral community.

Under the present LCDs, documentation requirements for manual wheelchairs and PMDs differ, although the basis of coverage is the same—the medical record. The manual wheelchair LCD does not demand that the medical record be obtained prior to dispensing product. It does state that if requested (as in prepay or postpay audit), it is expected to be made available. A KX modifier, illustrating the medical record is on file, is not mandated on manual wheelchair claims. However, an EY modifier is required if an order is not on file prior to billing.

Conversely, when supplying PMDs, suppliers must have all information outlined in the PMD LCD with proof that it was received within the mandated timeline.

Many physicians and clinicians who work in hospitals and rehab units are involved in prescribing both manual and power mobility. They depend on caseworkers or social service staff to facilitate their orders. Envision how confusing this becomes when different suppliers ask for different documentation for the same type of equipment, through the same payor, Medicare.

AN UNEVEN PLAYING FIELD IS EMERGING

Georgie Blackburn How do we effectively convey all of the new requirements without aggravating those who prescribe? When do we educate referrals? How do we educate referrals? It is a dilemma.

Some suppliers, attempting to protect company compliance under both policies, are requesting the relevant medical record up front, prior to providing any level of manual or power mobility. Recognizing that the PSCs have embarked on expanded audits, they are unwilling to risk that the information will not be there if requested.

Other suppliers are "marketing" to referrals by easing the referral process and not requiring the medical record up front for manual mobility. Essentially, those suppliers are willing to risk that (a) they will not be audited and/or (b) in event of audit, the information will exist somewhere in the patient chart.

There are even reports of referral sources playing one supplier against another, citing "Supplier A does not ask for all that information, why do you? I'm ordering from him." In many cases, this type of intimidation works, and suppliers back down and compromise company compliance.

Understandably, suppliers do not want to anger the referral sources that their businesses depend on. Some referral sources have even questioned the validity of requirements conveyed by suppliers because other suppliers do not express the same need. What is a supplier to do?

THERE ARE TIMES YOU MUST SAY NO!

Last winter, I was called by a "traveling" physician" (one who makes only house calls). He was offended that our firm had asked for specific information when providing a K0004 level wheelchair. He refused to forward any medical record information, explaining "I never write justification for equipment I order for patients…I write the order and if that is not sufficient, I will order from another supplier." He concluded, "My Hippocratic oath did not include writing medical documentation for suppliers." I told him that it probably was best he order the chair elsewhere. Our firm could not deliver product to his patient unless he assisted us with providing the information needed by our internal policy/procedure.

Requesting the medical record for manual wheelchairs greatly reduces supplier risk in audit; however, the LCD does not require it. For PMDs, all documentation must be on file prior to delivery within express timelines. CMS did not make the manual and power mobility guidelines simple or symmetrical. There was a time when the PSCs primarily audited larger national and regional firms, but that is no longer the case. Consider the levels and quantities of manual mobility your firm delivers. Is the volume enough to flag a PSC audit?

Suppliers must weigh the pros and cons of obtaining the medical record up front and determine the level of risk they can afford to take. Know that when your firm is audited (notice I did not say "if"), by obtaining the medical record up front for manual chairs as well as PMDs, you are more likely to keep your hard-earned money.

THE EDUCATIONAL CURVE WILL TAKE TIME

The final PMD LCD took effect Nov 15, 2006, and it is the "bible" when training staff or forming policies pertaining to PMD delivery. If audited, it is also important to know when certain guidelines were effective prior to the final policy: (a) a 30-day face-to-face exam was required from 10/25/05 until 1/01/06; from 1/1/06 until 4/1/06, a face-to-face was required but without the 30-day timeline; from 4/1/06 until 6/5/06, the 30-day face-to-face reactivated; on 6/5/06, the timeline changed to 45 days; (b) a detailed order prior to billing was required from 10/25/05 until 8/24/06; (c) as of 8/24/06, a detailed product description is required prior to delivery; (d) an LCMP attestation is required on all claims received on or after 8/10/06. Now suppliers must embrace the documentation requirements to make certain the money paid for our services is retained.

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: .