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Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
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Related Change Request (CR) #: 3952 Medlearn
Matters Number: MM3952
Related CR Release Date: September 14, 2005
Related CR Transmittal #: 121
Effective Date: May 5, 2005
Implementation Date: The implementation date for the Medicare system changes contained in CR3952 is April 3, 2006; otherwise, implementation will occur on October 17, 2005.
MMA – Evidence of Medical Necessity: Power Wheelchair and Power Operated Vehicle (POV)/Power Mobility Device (PMD) Claims
Provider Types Affected Providers prescribing Power Mobility Devices (PMDs) and suppliers billing Medicare Durable Medical
Equipment Regional Carriers (DMERCs) for PMDs.
Provider Action Needed
STOP – Impact to You Effective for dates of service on or after May 5, 2005, the procedure for documenting and submitting a claim for a wheelchair or PMD has changed.
CAUTION – What You Need to Know
Make certain to meet criteria regarding who can prescribe PMDs, retain appropriate prescribing documentation, and understand the boundaries for prescribing and billing for PMDs.
GO – What You Need to Do
Please be aware of the criteria addressed in the related instruction (CR3952) and ensure that billing staffs submit claims accordingly.
Background
This article includes information from Change Request (CR) 3952 that outlines the changes regarding Medicare adjudication of claims for PMDs as set forth in Section 302 (a) (2) (E) (iv) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA). Also outlined are criteria determining who can prescribe PMDs and a definition of the devices. The following rules are in place for claims with dates of service on or after May 5, 2005: Related Change Request #: 3952 Medlearn Matters Number: MM3952
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other
policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
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Rules for Adjudicating Claims for PMDs
Physicians should be aware of the critical role they play in prescribing power wheelchairs. Specifically, physicians evaluate a patient’s medical conditions and need for mobility and, as such, are the primary gatekeepers of the information CMS uses to base decisions for payment. To this end, physicians should be conscientious when documenting patient encounters and pay particular attention to describing the patient’s clinical condition (e.g., medical history, disease progression, changes in health status), as well as their need for mobility, their living situation (e.g., family support and caregivers), and other treatments that have been tried and considered. All of this information is used by our contractors (Medicare’s DMERCs) when evaluating a claim for payment Face-to-Face Examination and Prescription. A condition for payment for motorized or power wheelchairs is that the PMD must be prescribed by a physician or treating practitioner (a physician assistant, nurse practitioner, or a clinical nurse specialist) who has conducted a face-to-face examination of the beneficiary and written a prescription for the PMD. The face-to-face examination requirement does not apply when only accessories for PMDs are being ordered. The written prescription (order) must include the following:
- Beneficiary’s name;
- Date of the face-to-face examination;
- Diagnoses and conditions that the PMD is expected to modify;
- Description of the item;
- How long it is needed;
- The physician or treating practitioner’s signature; and
- The date the prescription is written.
The written prescription (order) must be in writing and signed and dated by the physician or treating practitioner (a physician assistant, nurse practitioner or clinical nurse specialist) who performed the face-toface examination, and be received by the supplier within 30 days after the face-to-face examination. The physician or treating practitioner must submit a written prescription (order) for the PMD to the supplier. This prescription must be received by the supplier within 30 days of the face-to-face evaluation, or in the case of a recently hospitalized beneficiary, within 30 days after the date of discharge from the hospital.
Additional Documentation
The physician or treating practitioner must also provide the supplier with additional documentation describing how the patient meets the clinical criteria for coverage as described in the National Coverage Determination (NCD) as documented in CR3791. (Instructions showing how to access CR3791 are in the Related Instructions section of this article.)
Related Change Request #: 3952 Medlearn Matters Number: MM3952
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other
policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
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The actual documentation needed to describe how the coverage is met varies, but may include the history, physical examination, diagnostic tests, summary of findings, diagnoses, and treatment plans, along with any other information explaining the patient’s need for the equipment. DME suppliers should retain on file the prescription (written order), signed and dated by the treating
physician or treating practitioner, along with the supporting documentation that supports the PMD as reasonable and necessary.
Other Rules
- It is no longer necessary to require a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology to provide a written order for POVs.
- The use of the Certificates of Medical Necessity (CMNs) for motorized wheelchairs, manual wheelchairs and power operated vehicles will be phased out for claims with Dates of Service (DOS) on or after May 5, 2005.
- Until Medicare systems changes are fully implemented in April 2006, for claims with dates of service on or after May 5, 2005, suppliers must submit a partially completed and unsigned CMN.
- For claims with dates of service before May 5, 2005, claims must be submitted and processed using the appropriate fully completed and signed CMN.
Implementation
The implementation date for the system changes contained in CR3952 is April 3, 2006; otherwise, implementation will occur on October 17, 2005.
Related Instructions
MM3791 provides additional information that describes the steps the health care provider must take to justify the POV. MM3791 lists the Clinical Criteria for MAE Coverage along with the MAE Coverage Flow Chart. Go to http://www.cms.hhs.gov/medlearn/matters/mmarticles/2005/MM3791.pdf on the CMS web site to view that information. For complete details, please see the official instruction regarding this change. The instruction includes the complete section 280.3; it may be viewed by going to http://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS web site.
From that web page, look for CR3791 in the CR NUM column on the right, and click on the file for that CR.
You will note two files for CR3791.
The file reflecting transmittal number 37 contains the revisions to the Medicare National Coverage Determinations Manual, and the file with transmittal number 574 contains the Medicare claims processing business requirements/instructions.
Related Change Request #: 3952 Medlearn Matters Number: MM3952
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
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Additional Information
For complete details regarding CR3952, please see the official instruction issued to your DMERC regarding this change. The instruction may be viewed at ttp://www.cms.hhs.gov/manuals/transmittals/comm_date_dsc.asp on the CMS web site. From that web page, look for CR3952 in the CR NUM column on the right, and click on the file for that CR.
If you have any questions, please contact your DMERC at their toll-free number, which may be found at
http://www.cms.hhs.gov/medlearn/tollnums.asp on the CMS web site.