Proper power mobility documentation can be confusing, but one of the keys is making it simple for the ordering practitioner and knowing exactly what you need in case of a postpay audit.
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| Peggy Walker, RN |
What works for power documentation—or what should work? The new LCD (local coverage decision) policy plainly states what they would “expect” to see, but who is “they” and did “they” read the policy as many times and as thoroughly as we have?
The physician is supposed to provide a prescription with seven elements: 1) the patient’s name; 2) the date of the face-to-face evaluation; 3) diagnosis and conditions that the power mobility device (PMD) is expected to modify; 4) description of the item (can be simply “power wheelchair” or scooter); 5) length of need; 6) ordering practitioner’s signature; and 7) signature date.
But what do we get? A 3 by 5 card with maybe the patient’s name, power wheelchair, and sometimes even a diagnosis that the physician may sign or have someone sign. What should you do when this happens? Upon first contact with ordering practitioners, send them a sample prescription/order form that does not have your letterhead on it.
Tools and Tactics
- Make sure ordering practitioners review and sign off on any PT/OT evaluations that have been ordered.
- Complete a detailed product description (detailed order) that includes: description and code of item being provided; your charge; and the Medicare allowable.
- Product descriptions should include all items being billed and exclude items that will not be billed.
- Product descriptions can be on your letterhead, but ordering practitioners must sign and date prior to delivery of the wheelchair.
- Ordering practitioners do not have to fill out any “forms” or write a “letter of medical necessity”—this just makes it harder for them.
- As the supplier, you must complete an in-home evaluation of the patient with the product (or similar device) at time of or prior to delivery.
- You must assess the home environment for accessibility, safety, and maneuverability. Address doorways, surfaces, clutter within the home, and ramps.
- If you complete the home evaluation, identify yourself clearly on the form, sign it, and date it.
- Have patients or family members sign the home evaluation to prove you were there.
Remember, the ordering practitioner must write the order. You can not type the information in like we do with a confirmation of verbal/telephone order for items not requiring a written order prior to delivery (WOPD).
Make it simple—put the physician’s information at the top, which helps to clarify signatures—and organize information like this:
- Physician’s name and address
- Patient name
- In the body of the order form, type in the date of the face to face (required for PMD)
- Diagnosis (related to need for mobility device)
- Length of need
- Item being ordered (power wheelchair or scooter)
- Physician’s signature_________
- Date _______
This information can be on a form that is headed “power mobility order” or whatever you choose to write as the header. This narrows the information down to what is actually needed to get you started.
The second step is educating ordering practitioners. Remember, supplier-generated “forms” would not be an acceptable piece of documentation for a postpay review.
You can send a simple explanation (not multiple pages) that explains that CMS has changed the rules on power mobility and the ordering practitioner needs to complete a face-to-face evaluation of the patient that must include:
- the fact that the patient is in today for an evaluation for a power wheelchair or scooter;
- the patient’s physical and cognitive condition and functional needs for mobility;
- a reminder to the physician that Medicare pays for mobility within the home and not just outside-the-home needs;
- why the patient is unable to ambulate functionally within their home and why a cane, walker, or manual wheelchair will not be adequate;
- why a scooter would not meet the patient’s needs (if ordering a power wheelchair); and
- an explanation that the patient is cognitively able to use a power wheelchair safely “in the home.”
It is important to keep this uncomplicated and explain to the ordering practitioner that it is simply a format similar to SOAP notes—subjective, objective, assessment, and plan.
Explain that they will bill Medicare with the 99211 code or variation thereof (99212 [focused], 99213 [more detailed]) just as they do for a yearly examination. In addition to the actual face-to-face billing, they can bill the G0372 code for faxing you over the documentation (progress notes) that is needed in your files. Remember, previously physicians were not compensated at all for providing paperwork to you, but this compensation will happen only if you get the documentation within 45 days of the face-to-face evaluation.
The next piece of the puzzle is making sure that they review and sign off on any PT/OT evaluation that has been ordered. Then you complete a detailed product description (detailed order) that includes: description and code of item being provided; your charge; and the Medicare allowable. This product description should include all items being billed and no items that will not be billed. This can be on your letterhead, but the ordering practitioner needs to sign and date it prior to delivery of the chair.
The physician is responsible for:
- the good order with the seven elements;
- the face-to-face evaluation;
- reviewing the detailed order;
- reviewing the PT/OT evaluation; and
- getting the information to the supplier within 45 days of the face to face. The 45 days start either at the initial face to face—when the PT/OT evaluation is reviewed—or at the discharge from hospital, rehab facility, or skilled nursing facility.
The supplier is responsible for:
- the home environmental evaluation (can be done at the time of or prior to delivery);
- the wheelchair specification (and any additional accessories needed);
- completing the detailed written order for physician’s review (specifications form);
- attestation statement if PT/OT is involved;
- education of patient/caregiver in use and care of equipment;
- delivery of the chair to the patient within 120 days of the face-to-face evaluation unless the item is being sent to Advance Determination of Medicare Coverage (ADMC), which would mean extra time; and
- any other documentation that is required in your policy and procedures manual.
What I just described is all the paperwork that is required for any power wheelchair or scooter. Ordering practitioners do not have to fill out any “forms” or write a “letter of medical necessity”—this just makes it harder for them. Instead they simply must do the following: examine the patient “face-to-face”; document the patient’s inability to ambulate safely and functionally within the home—even with the use of a cane, walker, or manual wheelchair; fax the information to you within 45 days; and review the detailed order and the PT/OT evaluation (if one is required).
As the supplier, you must complete an in-home evaluation of the patient with the product (or similar device) at the time of or prior to delivery. You must assess the home environment for accessibility, safety, and maneuverability. The doorways, surfaces, clutter within the home, and ramps should all be addressed.
The HME provider who completes this evaluation must be identified clearly on the form, and they must sign and date the form. There is nothing in writing that states the patient or family member should sign this form, but it is much safer for you if you make sure someone signs so you can prove you were there. Protect yourself in case there are questions in the future.
If there is a PT/OT evaluation, providers must write an attestation statement that basically states they have no financial relationship with the PT/OT completing the evaluation—on the particular patient, on the specific date.
There is always going to be the physician/ordering practitioner who says, “Just fill out a form and I will sign it.” This is not acceptable, and regardless of what your competitors are doing, you are putting your company at risk if you do the same thing. If your competitor does this, report it to your DME Medicare Administrative Contractor fraud unit.
Of course, these are the basics and you would follow your normal billing procedures, order intake, verification of insurance, checking proper coding, and billing—all with appropriate modifiers.
In evaluating a patient for any mobility device, it is important to remember that you need to fit the patient to the chair and not the chair to the patient.
You will see code K0823 in the greatest numbers in billing. Understand that not every patient needs the same type of chair. There are other codes within the group 2 category that may fit the needs of the patient satisfactorily. There are group 1 chairs that are perfectly adequate for patients who are intermittent users or low functioning, and only in the chair a minimal amount of time. Sometimes these smaller chairs may not be as sturdy, but they may not have to be.
SCOOTER: A LEISURE DEVICE?
Many patients who want a scooter see it as a means to accomplish leisure activities, such as shopping or going on outings with family and friends. There are instances where a power operated vehicle (POV) will fit in a patient’s home, and it is all they really need (but this is usually rare). When explaining the criteria for these items, understand that this is not the reason they would be covered by Medicare—and sometimes it is just easier to explain and let the patient purchase the POV outright. If they want you to bill it, simply bill using the EYGA modifier indication that there is no physician’s order on file.
It would be unlikely to see 75 patients in a small rural area needing a K0823 in a period of a few months. These are situations that should be watched closely. Do not allow yourself to be too complacent about just putting out a specific base consistently. If the product is needed, then it is covered, and you should have the documentation to back it up in a postpay audit.
If you have the documentation “in your file” when you bill, put the KX modifier on the claim. If that documentation is not “in your file,” then your company is put at risk for filing a false claim. In a postpay audit, the money would be recouped and further action could be taken. The best thing for all of us to do is continue to care for the end user in the most economical way possible without risking our values and ethics.
Peggy Walker, RN, is billing and reimbursement advisor for US Rehab/VGM, Waterloo, Iowa. Walker can be reached via e-mail: .
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