Transitioning to the Mobility Assistive Equipment National Coverage Determination
The Centers for Medicare and Medicaid Services (CMS) released a National Coverage Determination (NCD) addressing Mobility Assistive Equipment effective for dates of service on or after May 5, 2005. Use the information in this article as a roadmap through the transition.
General Information about the New NCD
In the attached NCD, 280.3—Mobility Assistive Equipment (MAE), the clinical criteria for coverage of Mobility Assistive Equipment (MAE) are described in a series of nine questions and definitions. They are also illustrated in a flow chart to assist understanding the coverage criteria. Some of the issues addressed in the NCD are:
- What are mobility related ADLs?
- How does the NCD apply to different types of equipment?
This new NCD provides the foundation for all claims adjudication for dates of service on or after May 5, 2005. Previous national and local coverage criteria remain in effect for claims with dates of service prior to May 5, 2005. Please take the time to review the entire document and become familiar with its provisions. Suppliers are strongly encouraged to review the NCD with their referring physicians.
Implementation of the New NCD
Current LCDs
The basic coverage criteria contained in the Motorized/Power Wheelchair Bases and Power Operated Vehicles are no longer applicable for dates of service on or after May 5, 2005. However, the other provisions of each LCD remain in effect. The Policy Articles for these policies remain in effect, also.
The DMERCs plan to release a draft Power Mobility LCD for comment during the next few months and anticipate that it will be effective in January 2006.
The basic wheelchair coverage criteria contained in the Manual Wheelchair Base LCD are no longer applicable for dates of service on or after May 5, 2005. However, the provisions concerning specific manual wheelchair bases remain in effect.
The basic coverage criteria contained in the Walkers and Canes and Crutches LCDs are no longer applicable for dates of service on or after May 5, 2005. However, the provisions concerning specific items remain in effect. Revisions including the NCD criteria are planned for a future policy revision.
The LCDs on Wheelchair Options and Accessories and Wheelchair Seating and Positioning remain in effect.
Certificates of Medical Necessity
The DMERCs will continue to use the existing CMNs for Manual Wheelchairs (CMS 844), Motorized Wheelchairs (CMS 843), and Power Operated Vehicles (CMS 850) to facilitate claims adjudication.
For dates of service on or after May 5, 2005, question #1 on both the Manual Wheelchair and Motorized Wheelchair CMNs and question #6 on the POV CMN will refer to the newly released NCD provisions. Thus if a patient requires the use of a wheelchair to accomplish his/her mobility-related ADLs in the home, as described in the Mobility Assistive Equipment NCD, this question should be answered with a “Y�.
Manual Wheelchair (CMS 844) questions 2 – 9 are still applicable under existing LCDs.
Motorized Wheelchair CMN (CMS 843) questions 2 – 5 and 7 are still applicable under existing LCDs. Question 6 is no longer applicable and may be left unanswered. Suppliers may enter a “D” in the answer field for electronic CMN submission when the question is unanswered.
Power Operated Vehicle CMN (CMS 850) questions 7 – 14 are still applicable under the existing LCD.
Table 1 is included (click on View Attachments) summarizing these CMN instructions.
Documentation
Section 1833(e) of the Social Security Act precludes payment to any provider of services unless “there has been furnished such information as may be necessary in order to determine the amounts due such provider” (42 U.S.C. section 1395l (e)). It is expected that the patient’s medical records will reflect the need for the care provided. The patient’s medical records include the physician’s office records, hospital records, nursing home records, home health agency records, records from other healthcare professionals, and test reports.
Suppliers are reminded that they may be asked to provide information that corroborates the medical need for the item provided in the event of a Medical Review audit or Benefit Integrity investigation. We encourage suppliers to work with their referral sources to ensure the adequacy of the medical record.
Additional information relating to documentation of medical necessity will be included in the Power Mobility LCD planned for later in 2005.