Functionality, effectiveness, durability, and versatility are all at the top of the list when choosing exercise and therapy equipment.
It was not long ago that life in the DME policy world was pretty simple. The DMERCs wrote a policy and published it in their newsletters, and that was all there was to it. Times have changed. Today, there is a wealth of supplementary information beyond the actual policies themselves that play a crucial role in the DME business arena.
In the current Medicare environment, providers have more of an opportunity to interact with the DME MACs through a variety of organizations and forums. While the nature of these avenues of communication varies by jurisdiction, they offer direct interaction with Medicare contractors and often allow providers to ask the DME MACs pointed questions on policy specifics. In some cases, these discussions lead to the DME MACs publishing articles or frequently asked questions (FAQs) that provide additional guidance on certain portions of a medical policy.
Several policies have been affected in such a manner and the power mobility device (PMD) policy is a perfect example. Knowing what’s in the actual policy itself is important and serves as the baseline and number one source to consult for specifics. Knowing what additional articles, FAQs, and other publications are available and relevant is also extremely important in the day-to-day practice of your operation. Here we’ll look at some key points in the policy as well as some important factors that have been published to provide some additional guidance. We’ll focus specifically on the PMD policy and clarifications that are relevant to the complex rehab provider.
The LCD—The Local Coverage Determination is commonly referred to simply as the “medical policy.” The PMD policy is based on a fairly simple premise. First, determine that the beneficiary has a mobility deficit. Then, figure out what item is best suited to help resolve that deficit, starting with a cane and working your way up to a complex rehab power chair. This is commonly referred to as the mobility assistive equipment (MAE) algorithm and is built into the coverage section of the policy. There are some basic elements of the LCD that every provider needs to be aware of when compiling their documentation. The medical/clinical documentation should paint a picture of the patient’s condition. This is done via a face-to-face (FTF) examination by the ordering physician and should include chart notes, progress notes, clinical assessments, and any other pertinent information. Two other key components that the policy requires are a seven-element prescription and a detailed product description (DPD). The PMD LCD states that wheelchairs, classified as Group 2 with a single or multiple power option, Group 3, Group 4, Group 5, and push rim activated power assist for manual wheelchairs, must be provided by a supplier employing a RESNA-certified assistive technology professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection.
As mentioned, there is additional guidance published by the DME MACs in a series of FAQs, articles, and newsletters. It is important to be aware of these as they have implications for the policy and review of claims submitted. Here are a few examples of the key information that can be found in these publications.
July 2007 FAQs—Three basic but important issues are discussed in this initial set of FAQs. The first is the idea that a form that is developed by an entity other than the supplier, completed and signed by the physician, and included in the patient’s chart will not be considered sufficient documentation of the required FTF examination for PMDs. It is reiterated that physicians must document the FTF examination “in a detailed narrative note in their charts in the format that they use for other entries.” The second clarifies the definition of a “financial relationship” between a supplier and a PT or OT. In cases where a provider pays a PT or OT to do wheelchair evaluations of non-Medicare patients, the PT or OT is considered to have a financial relationship with the provider. Therefore, even though the provider does not pay the therapist for the evaluation of the Medicare beneficiary, their evaluation cannot be considered part of the required face-to-face examination for any Medicare PMD. Nor can it be submitted as the required specialty evaluation for complex rehab PMDs (Group 2 single power and above). Finally, in the third clarification, they instruct that a physical therapy assistant (PTA) or an occupational therapy assistant (OTA) cannot provide the specialty evaluation for complex rehab PMDs.
October 2007 PMD FAQs—This set of FAQs examines the complexities of the PMD policy in a real world setting. One important distinction made in this question set is the requirement that the seven-element prescription and the DPD must be two separate documents. The seven-element prescription is a document that is written by the physician after completion of the FTF process. The DPD is a document that is prepared by the supplier and sent to the physician after the supplier receives the seven-element prescription and the supporting documentation from the physician. Another important point made in this question set is in regard to a provider facilitating a PT/OT evaluation when the physician faxes the request for a PT/OT evaluation to the supplier. Per the FAQs, the physician should take care of the referral directly. If the supplier receives the PT/OT order, they may pass it along to the physician-selected therapist. Finally, these FAQs are the first time that the FTF examination date is discussed in depth in cases where the examination involves more than one visit. When this occurs, the date of the FTF examination that is entered on the seven-element order by the physician is the date of completion of the entire FTF process.
May 2008 PMD FAQs—This set of FAQs deals specifically with the ATP requirement mentioned in the policy. At the time of publication, the RESNA certifications that existed were assistive technology suppliers (ATS) or assistive technology professionals. Several important points regarding the ATP are drawn out in these FAQs. The first point clarified in this question set is that the ATP must be employed by a supplier in a full-time, part-time, or contracted capacity as acceptable by state law. The ATP, if part-time or contracted, must be under the direct control of the supplier. The supplier should be able to provide evidence of employment as well as the ATP certification upon request. The ATP “having direct, in-person involvement in the wheelchair selection” means they must physically see and interact with the patient face-to-face. It is important that the record show how the ATP was involved and that medical personnel drove the process. While there is no mandate as to how suppliers document compliance with the ATP requirement, there must be evidence in the supplier’s file of direct face-to-face interaction by the ATP. Documentation must be complete and detailed enough so a third party would be able to understand the nature of the ATP involvement and determine that the standard was met. Just signing off on a form completed by another individual does not adequately document involvement. The supplier’s ATP need not necessarily be present for the delivery, fitting, and/or patient training for the wheelchair provided. The policy simply states the credentialed ATP must have direct, in-person involvement with the equipment selection process. Review of a live video feed or videotaped evaluation would not meet the requirements of the policy. “Direct, in-person involvement” means just that—a live, in-person interaction between the ATP and the beneficiary.
Keeping track of the relevant issues outlined in policy and supplemental publications can be challenging, but doing so will help assure that your rehab business will be run in the most effective, cost-efficient, and compliant manner possible.
Paul Komishock is general manager of Government Affairs for Pride Mobility Products Corp, Exeter, Pa. Komishock can be reached via e-mail at or (800) 800-8586.