What if tax returns were subjective? Without some scrupulously detailed government form to guide us, think how the process of filing taxes might be different: no little numbered boxes, and no step-by-step instructions to tell us what information goes where. What if the Internal Revenue Service (IRS) instead simply asked: “Tell us what you think we want to hear. Write out a little narrative which we in the office can enjoy over coffee and, if we like it, we’ll get back to you.”
The IRS knows that idea won’t work, so it offers form 1040 as a way to prevent accounting Armageddon. In the health care context, form 1040 might be thought of as a “template,” a tool that can help organize the minutiae of details associated with medical documentation. And, in a perfect world, a template reduces errors and increases efficiency for medical documentation tasks, right? But that’s not how they see it at the Centers for Medicare and Medicaid Services (CMS). That agency recently declared it would not provide a clinical template for a new program that require prior authorization of power mobility devices (PMDs). This move, to me, suggests that CMS thinks it’s still the Wild West when it comes to documenting need for a PMD order.
Beginning September 21, CMS will require prior authorization to be submitted for all power mobility claims made in seven states. This “demonstration” program is scheduled to run for the next 3 years. On the surface, the program might not seem like a terrible idea, since it theoretically would assure PMD orders are approved before a provider even orders the first part. But what if the physician gets the documentation behind the order wrong? What if a piece of data gets overlooked? A recent Comprehensive Error Rate Test (CERT) report revealed a 100% error rate on medical necessity documentation for PMDs in 17 states. The point this makes, according to a statement by the American Association for Home Care, is that “CMS guidelines for documenting medical necessity for mobility devices are so subjective and absurd that virtually any reimbursement claim can be found to be in non-compliance.”
A clinical template could help solve this problem. Such a tool would help direct physicians in their documentation of patient need, and make it easier to verify that all objective and necessary information appears on the template at the time a claim is made. If the government can produce form 1040 to keep tax collection from falling apart at the seams, surely it could craft a document that would streamline PMD orders. In fact, if CMS would simply spell out exactly what information should appear in a clinical template for physicians, I’ll bet there are a dozen medical record software manufacturers that could build one into their electronic health record software products, and have it ready for market in a matter of weeks.
Some mobility providers currently offer templates or guidelines for letters of medical necessity, but there is not a single template that can be used in all cases for all patients. There certainly is not one for prior authorization. CMS must have a pretty good reason for not wanting to issue this template. But darned if I can find it. My advice to clinicians is to stop trying to make sense of the CMS decision. Instead, get up to speed about what lies ahead in the prior authorization of PMD demonstration. CMS offers a video briefing about the program on YouTube. In the search field, enter “PMD Demo—Documentation Requirements.”
—Frank Long
