Peggy Walker, RNPeggy Walker, RNUS Rehab/VGMUS Rehab/VGM800-401-3643800-401-3643

803-754-2091fax803-754-2091fax877 907 3862 V-fax877 907 3862 V-fax

peggy.walker@usrehab.comUPD AND REVIEWED 01/27/2014UPD AND REVIEWED 01/27/2014

PMDs DOING IT RIGHTPMDs DOING IT RIGHT

The Rules are still the same just make sure you The Rules are still the same just make sure you understand themunderstand them

Presented for GAMES 2/4/2014

Yes – A good order with the 7 elements Patient information – name Date of F2F (can be date seen by physician (for

basic eq. Or has to be date clinical evaluation reviewed by physician for complex rehab.

(this is the date of the “completion of” the F2F) and when the time frame starts.

Length of need Diagnosis Item being ordered Physician signature --- date --- NPI Supplier needs to have this “prior” to completing

the detailed product description. **** Suggest adding NPI after July 1, 2013****

Do I have to have it?

1. Ordering practitioner sees client and completes all 9 areas of F2F general notes in his normal charting format. (SOAP notes)

{F2F date would be this date} 2. Physician does an evaluation and refers to clinician for mobility eval

– The clinician sends back to physician for review and signature. {F2F date would be date he signs off on clinical notes}

3. Physician Refers to OT/PT first and then “completes” his part of the evaluation and reviews PT/OT notes –

{F2F date would be date he sees client his part of the evaluation and signs off on OT/PT notes}

4. If in seating clinic – the physician, the therapist, and the ATP can be in attendance at the same time.

REMEMBER the seating evaluation by the clinician is “in addition to” not

“in lieu of” or “instead of” the physicians evaluation per the LCD policy.

In the hospital setting the F2F date would be the date of discharge from

the hospital but mobility needs would have to be noted in hospital chart notes/PT/OT notes etc.

Written Orders CMS response per Dr. Hoover. Written Orders CMS response per Dr. Hoover. {5/27/2009}{5/27/2009}

“I have received clarification from CMS on the form in which the 7-element order may take. As you recall, there was some debate regarding whether or not the 7-element order was required to be “handwritten” by the physician or whether or not it could be computer-generated as part of an electronic medical record/electronic order.

As noted in the PIM Chapters 3.4.1.1,B and 5.2.3, written orders can be in the form of photocopy, facsimile image, electronically maintained or original pen and ink document. The treating physician must still complete all 7 elements him/herself. Suppliers may provide a form with “BLANK” spaces for the “7 ELEMENTS” but MUST NOT complete any of the elements.

NO STAMPED SIGNATURES

CR 5971 Clarification - Signature RequirementsReference: MLN: SE0829Published Online: 7/31/2008

Provider Types AffectedPhysicians and other providers who bill MedicareContractors (Carriers, Fiscal Intermediaries, RegionalHome Health Intermediaries, Part A/B MedicareAdministrative Contractors, including Durable MedicalEquipment Medicare Administrative Contractors) for careprovided to Medicare beneficiaries.

What You Need to KnowThe purpose of this notice is to provide guidance toproviders/suppliers and Medicare contractors on the useof stamped signatures. Note that stamped signatures arenot acceptable on any medical record.

No Stamped Signatures

7 element order7 element order 1. Patient name _____________ 2. Date of completion of face to face _________ 3. Diagnosis related to mobility impairment ____________ 4. Length of Need _____________ 5. Item being ordered: ____________ 6. Physicians Signature ____________ (print name) ______________ NPI _________ 7. Date: _________________

NOTE denials received using 2 dates in all jurisdictions 3/2013

NPI required on F2F items implemented 7/1/13 suggest adding to the 7 element order to prevent denials from auditors.

7 element order7 element order Patient name __________Patient name __________ Date of COMPLETION of F2F __ __ ____ Date of COMPLETION of F2F __ __ ____ Diagnosis ___________Diagnosis ___________ Item ordered ___________Item ordered ___________ Length of Need ___________Length of Need ___________ Physicians Signature ________ NPI _____Physicians Signature ________ NPI _____ Print signature: ______________Print signature: ______________ Date _____Date _____

Denial reasons seen for 7 element Denial reasons seen for 7 element order order

none receivednone received left off bene nameleft off bene name left off F2F dateleft off F2F date left off description of item orderedleft off description of item ordered left off Length of needleft off Length of need left off diagnosisleft off diagnosis No physicians signature or signature not legibleNo physicians signature or signature not legible Physician did not personally complete all elements of orderPhysician did not personally complete all elements of order Date stamp or equivalent missingDate stamp or equivalent missing Order dated BEFORE completion of F2FOrder dated BEFORE completion of F2F Supplier did not receive within 45 days of completion of F2FSupplier did not receive within 45 days of completion of F2F Ordering physician was a podiatrist(DPM) or Chiropractor (DC)Ordering physician was a podiatrist(DPM) or Chiropractor (DC) 7 element on form with item preprinted or check boxes or other 7 element on form with item preprinted or check boxes or other

prompts that may be leading physician as to what to orderprompts that may be leading physician as to what to order 7 element order combined with detailed written order. 7 element order combined with detailed written order.

Keep it simple Tell them why & who {not me} CMSWhen it became effective & how they can get paid (not just the G0372 code) 99211 –99212 for E & M billing according to time

spent Outline the “good order” for them Talk only briefly about the algorithm in progress

format using “SOAP” note format (H & P) History & physical

{subjective/objective/assessment/plan}

What do I do to educate the ordering practitioner?

Face to Face Progress Notes Must Include in normal charting format {H & P /SOAP

Notes}History of the present condition(s) and past medical history that is relevant to mobility needs: *** NOTE __ this can be a combination of physicians’ and clinical evalution***

Symptoms that limit ambulationDiagnoses that are responsible for these symptomsMedications or other treatment for these symptoms Progression of ambulation difficulty over timeOther diagnoses that may relate to ambulatory problemsHow far the patient can walk without stoppingPace of ambulationWhat ambulatory assistance (cane, walker, wheelchair, caregiver) is currently usedWhat has changed to now require use of a power mobility deviceAbility to stand up from a seated position without assistanceDescription of the home setting and the ability to perform activities of daily living in the home

•Physical examination that is relevant to mobility needsWeight and heightCardiopulmonary examination Musculoskeletal examination

oArm and leg strength and range of motionNeurological examination

oGaitoBalance and coordinationThe evaluation should be tailored to the individual patient’s conditions. The history should paint a picture of the patient’s functional abilities and limitations on a typical day. It should contain as much objective data as possible. The physical examination should be focused on the body systems that are responsible for the patient’s ambulatory difficulty or impact on the patient’s ambulatory ability.

The home environmental evaluation should address what CMS has outlined

Make it brief –if the one you have covers this than continue to use it. Do what you are comfortable with.

If it is 2 pages make sure if you send it in to ADMC that you number all pages

Make sure if you have a line to complete that you either complete or put N/A

Have the patient/caregiver sign & date (not required but safer so you can prove you did do it)

**Should come “after” receiving the 7 element order from physician**

LEGIBLE _ SIGNATURES AND NOTES

ABC Company

Patient name:____________________________________ Date of Assessment: ___________Address: ____________________________________________________________________ ____________________________________________________________________Completed by: __________________________________________________________ Housing Type: Apartment Single story house Two story house Mobile

home Independent living Group home Other ______________________

Comments: _________________________________________________________________Surfaces: Carpet Linoleum Hardwood Other Comments: _________________________________________________________________Space: Cluttered Open Small rooms Narrow hallwaysComments: __________________________________________________________________Accessibility: Bedroom: Yes No Bathroom: Yes No Kitchen:

Yes NoLiving/family room: Yes No Dining room: Yes No Other: Yes No Comments: __________________________________________________________________Ramps or steps within the home: Yes No ____________________________________________________________________________Measurements (indicate widths): Entry doors _____ Bathroom _____ Kitchen _____ Bedroom ______ Living/family room ______ Hallways ______ Other ______________

Entrance: Ramp Steps (how many) _______ Low threshold Sliding glass door

Comments: __________________________________________________________________Outside access: Paved Gravel Dirt Flagstone Other ______________Recommendations: ________________________________________________________________________________________________________________________________________ Patient and/or caregiver/family member is willing and able to use the mobility device

safely and adequately to assist with MRADLs in the home Yes No

Patient / Caregiver signature __________________________________ Date __________ Why patient unable to sign if caregiver signs: ________________________________________

Supplier’s signature/ATP _____________ (print name)______________ Date _________

Environmental Assessment

Required on any grp 2 (single power option) or greater that requires specialty controls or seating

{ALL group 3s ; 4s; and MWCs with power assist device}

K0005s & E1161s --- March 1, 2013 Required on all custom seating THE SUPPLIER must do an attestation statement of no

financial relationship with PT/OT completing the evaluation – for each patient – hospital owned DMEs exempt.

PTs/OTs have different codes they can bill 97001 for PT – 97003 for OT plus they can bill 97755 for time (1 U =s 15 min) they need to check their region for clarification on allowable. NOT all states are the same & some areas do not even pay for these.

A clinical evaluation does not take the place of a F2F by ordering practitioner (in conjunction with but does not take place of)

Company Letterhead

Attestation Statement:This is to attest that ABC company has no

financial relation ship with (name, PT/OT) completing the evaluation for (patient name) on (date).

Signature: Date:Title:(Can be completed and signed by supplier or therapist)HAS TO BE A SEPARATE FORM – AUDITORS ARE DENYING

Must contain: * Patient information * Brief description of item (name/model)****** DATE of FACE to FACE completion**** * HCPCs Code (DESCRIPTION OF) ie:grp2pwc M41

INVEACH accessory must have complete description * * Must be signed and dated prior to delivery * If all or part changes a new order would be

required. **** MUST come “AFTER” the 7 element order******** Must be completed prior to delivery of

equipment**** {medical necessity for each accessory

required}NO LONGER REQUIRES PRICING retroactive to

October 2009 - Q & As Jurisdiction C July 25, 2011

ABCD CompanyAnywhere Street

Any Town – USA 55555555-555-5555

Beneficiary Name:Address:Date of F2F __ __ ____

(this is initial / start date) Dear Doctor ________)

This is a detailed order for wheelchair base and all accessories thatare required for your patient to maintain mobility – please review and if you agree sign and date below.

Code Description Your charge** Medicare Allowable**

(base and all accessories) UPGRADES USE BOTH CODES AND CLEARLY IDENTIFY WHAT THEY

ARE

Physician _____________________ Date ___

Print Name: ___________________

• Note*This can be completed by supplier for ordering practitioner to review and sign off & should include all items being billed. Medical necessity for “in the home” must be documented in clinical format for the base and each accessory billed.

**Pricing No longer required June 1, 2011**

Denial Reasons Seen Denial Reasons Seen Not received or was within the therapist notes not Not received or was within the therapist notes not

separateseparate Did not have separate listing for base and each Did not have separate listing for base and each

option/accessory to be billed option/accessory to be billed Does not provide enough detail information to Does not provide enough detail information to

determine the item was properly coded (manf name determine the item was properly coded (manf name and product number)and product number)

DPD was combined with 7 element order (by policy the DPD was combined with 7 element order (by policy the DPD can’t be completed until the supplier has received DPD can’t be completed until the supplier has received the 7 element order.the 7 element order.

Documentation does not support that the supplier Documentation does not support that the supplier received, prior to delivery, a DPD that was signed and received, prior to delivery, a DPD that was signed and dated by physiciandated by physician

Missing Date Stamp or equivalentMissing Date Stamp or equivalent Corrections/changes made without physicians’ initials Corrections/changes made without physicians’ initials

and datedand dated

November 12, 2009Power Mobility DevicesDetailed Product Description – Clarification

In a revision of the Power Mobility Devices Local Coverage Determination that became effective on 10/1/09, the requirements for the detailed product description were revised. The LCD states:For the wheelchair base and each option/accessory, the supplier must enter all of the following:HCPCS code Narrative description of the HCPCS code Manufacturer name and model name/number Supplier's charge **** no longer required (June 2011) Medicare fee schedule allowance ****revised and removed June 2011 retroactive to 2009 BUT even the ADMC nurses are denying if not there***

2011 CB Modifier updates// note date here (this is not what 2011 CB Modifier updates// note date here (this is not what they are using) -- KT is still used for traveling / KE & KY for they are using) -- KT is still used for traveling / KE & KY for

accessories 2013accessories 2013 MLN SE1035 January 1/17/2010 KE – use on accessories billed on a manual wheelchair K0001

through K0009 that could be billed on a competitive bid power wheelchair *** USE even if in non CB area***

KG modifier is on accessories billed with standard power chairs K0813 through K0829 for beneficiary who permanently lives in a CB area ( If not in CBA area do NOT use KE or KG)

KK modifier is to be used on accessories billed with Complex Rehab power wheelchairs in Group 2 (K0835 – K0843) if beneficiary lives in a CBA area – KK used for CB area for complex rehab ELRs in CB

Complex Rehab Group 3 K0848 thru K0864 do not use any of the CB modifiers ( KE/KG or KE) ***KE****

The CB modifiers (KG/KK/KU/KW) are only used on beneficiaries who live in a CBA (**KT **use if traveling out of CBA)

These modifiers are to be used in CBA by CB winners. KY is temporary modifier for grandfathered suppliers to use in

CBAs which will change in future (October 1, 2011) no longer use

 

KG KK KL CB Modifiers for power accessoriesKG KK KL CB Modifiers for power accessories Competitive Bid Modifiers for power wheelchairs KG/KK ** not using** Competitive Bid Modifiers for power wheelchairs KG/KK ** not using** The denial s/rejections will happen if not used correctly in the CB areas.The denial s/rejections will happen if not used correctly in the CB areas. K0195 or E0990 for ELRs (& any other accessories) should have the KG when K0195 or E0990 for ELRs (& any other accessories) should have the KG when

billing for standard power chair (such as K0822; K0823 or K0825) * anything billing for standard power chair (such as K0822; K0823 or K0825) * anything in the K0813 through K0831 group) but the KK if billed for the complex rehab in the K0813 through K0831 group) but the KK if billed for the complex rehab bases. Group 3s or any other Group 2 bases that is not in the CB range.bases. Group 3s or any other Group 2 bases that is not in the CB range.

Accessories that can be billed on both the CB bases and the Non CB bases Accessories that can be billed on both the CB bases and the Non CB bases will require these modifiers.will require these modifiers.

List of common codes where the modifiers are left off are:List of common codes where the modifiers are left off are: E0990KK (purchase ELRS for complex) K0195KG (rental ELRs for basic powerE0990KK (purchase ELRS for complex) K0195KG (rental ELRs for basic power E0973 (adj hgt arm rests) E2361 (batteries) E2365 (batteries) E0951 (heel E0973 (adj hgt arm rests) E2361 (batteries) E2365 (batteries) E0951 (heel

loops) E0955 (head rest)loops) E0955 (head rest) E1028 (swing away hardware) ---Anti tips should not be billed with power E1028 (swing away hardware) ---Anti tips should not be billed with power

chairs – chairs – If a fully reclining back is billed (and is truly a “fully” {greater than 80 If a fully reclining back is billed (and is truly a “fully” {greater than 80

degrees} reclining back E1226 would require these modifiers as degrees} reclining back E1226 would require these modifiers as well. well.

NOTE these are not being used in 2013 just for reference –NOTE these are not being used in 2013 just for reference – KE for accessories for complex rehab manual (E1161/K0005s/ and KE for accessories for complex rehab manual (E1161/K0005s/ and

manual tilt in spaces even pediatric.manual tilt in spaces even pediatric. KY for complex group 3 accessories in or not in CB areas.KY for complex group 3 accessories in or not in CB areas.

PMD Revisions June 1, 2011PMD Revisions June 1, 2011 K0822 – will deny -For patients who do not have special skin protection or K0822 – will deny -For patients who do not have special skin protection or

positioning needs, a power wheelchair with Captain’s Chair provides appropriate positioning needs, a power wheelchair with Captain’s Chair provides appropriate support. Therefore, if a general use cushion is provided with a power wheelchair support. Therefore, if a general use cushion is provided with a power wheelchair with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the with a sling/solid seat/back instead of Captain’s Chair, the wheelchair and the cushion(s) will be covered only if either criterion 1 or criterion 2 is met:cushion(s) will be covered only if either criterion 1 or criterion 2 is met:The cushion is provided with a covered power wheelchair base that is not The cushion is provided with a covered power wheelchair base that is not available in a Captain’s Chair model – i.e., codes K0839, K0840, K0843, K0860 – available in a Captain’s Chair model – i.e., codes K0839, K0840, K0843, K0860 – K0864, K0870, K0871, K0879, K0880, K0886, K0890, K0891; or A skin protection K0864, K0870, K0871, K0879, K0880, K0886, K0890, K0891; or A skin protection and/or positioning seat or back cushion that meets coverage criteria is provided.and/or positioning seat or back cushion that meets coverage criteria is provided.

If one of these criteria is not met, both the power wheelchair with a sling/solid If one of these criteria is not met, both the power wheelchair with a sling/solid seat and the general use cushion will be denied as not reasonable and seat and the general use cushion will be denied as not reasonable and necessary.necessary.

ABNs seat elevator bases updates revised JUNE 1, 2011ABNs seat elevator bases updates revised JUNE 1, 2011 Not reasonable and necessary means you can now use ABNs again for chairs Not reasonable and necessary means you can now use ABNs again for chairs

with seat elevator.with seat elevator. If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is If a Group 2 Single Power Option PWC is provided and if criterion II(A) or II(B) is

not met (including but not limited to situations in which it is only provided to not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation feature, a power standing feature, or accommodate a power seat elevation feature, a power standing feature, or power elevating leg rests), it will be denied as not reasonable and necessary. power elevating leg rests), it will be denied as not reasonable and necessary.

Group 4 also same revision with effective date of June 1, 2011.Group 4 also same revision with effective date of June 1, 2011. These are effective as of June 1, 2011 and this basically means that an ABN can These are effective as of June 1, 2011 and this basically means that an ABN can

be used for the Group 2 bases that the patient “Wants” a seat elevator as well be used for the Group 2 bases that the patient “Wants” a seat elevator as well as the Group 4 that patient wants but meets for a group 3 or lower.as the Group 4 that patient wants but meets for a group 3 or lower.

Revisions June 1, 2011Revisions June 1, 2011 Not reasonable and necessary denial means you can now use Not reasonable and necessary denial means you can now use

ABNs again for chairs with seat elevator.ABNs again for chairs with seat elevator. If a Group 2 Single Power Option PWC is provided and if criterion If a Group 2 Single Power Option PWC is provided and if criterion

II(A) or II(B) is not met (including but not limited to situations in II(A) or II(B) is not met (including but not limited to situations in which it is only provided to accommodate a power seat elevation which it is only provided to accommodate a power seat elevation feature, a power standing feature, or power elevating leg rests), feature, a power standing feature, or power elevating leg rests), it will be denied as not reasonable and necessary. it will be denied as not reasonable and necessary.

Group 4 also same revision with effective date of June 1, 2011.Group 4 also same revision with effective date of June 1, 2011. These are effective as of June 1, 2011 and this basically means These are effective as of June 1, 2011 and this basically means

that an ABN can be used for the Group 2 bases that the patient that an ABN can be used for the Group 2 bases that the patient “Wants” a seat elevator either billable or free upgrades“Wants” a seat elevator either billable or free upgrades

Group 4 that patient wants but meets for a group 3 can now Group 4 that patient wants but meets for a group 3 can now accept ABNs or free upgrades. accept ABNs or free upgrades.

Can do the K0831 to the K0823 again.Can do the K0831 to the K0823 again. K0822 and general use cushion and backs – US Rehab/VGM and K0822 and general use cushion and backs – US Rehab/VGM and

other industry experts are requesting revision of this policy to other industry experts are requesting revision of this policy to allow the rehab seat and general use cushion /less cost to allow the rehab seat and general use cushion /less cost to Medicare trust fund & increases beneficiary access to Rehab Medicare trust fund & increases beneficiary access to Rehab seating backs heights and widths can’t get with captains’ seats.seating backs heights and widths can’t get with captains’ seats.

PWK additional PWK additional documentationdocumentation NOTE- Medicare now has the PWK segment which allows a supplier to NOTE- Medicare now has the PWK segment which allows a supplier to

submit paper documentation by fax or mail along with your electronic submit paper documentation by fax or mail along with your electronic claim BEFORE it is requested by the DME MAC. To submit PWK claim BEFORE it is requested by the DME MAC. To submit PWK documentation with your claim, you must complete the PWK segment documentation with your claim, you must complete the PWK segment with a value of either BM (if mailing documentation) FX (if faxing). with a value of either BM (if mailing documentation) FX (if faxing). AFTER the claim has been accepted by CEDI, complete the PWK AFTER the claim has been accepted by CEDI, complete the PWK Fax/Mail cover Sheet and mail or fax the cover sheet along with your Fax/Mail cover Sheet and mail or fax the cover sheet along with your documentationdocumentation

This became available beginning This became available beginning Oct 1, 2012 in all Oct 1, 2012 in all jurisdictions – copy of A, B, C and D forms attached. jurisdictions – copy of A, B, C and D forms attached.

Each Jurisdiction has a form to be attached to the Each Jurisdiction has a form to be attached to the additional documentation submission that you can find additional documentation submission that you can find on their web site under forms. B is very difficult to find on their web site under forms. B is very difficult to find and is titled Medicare DMEC fax Medicare cover sheet and is titled Medicare DMEC fax Medicare cover sheet instead of PWK cover sheetinstead of PWK cover sheet

Prior Authorization Demo Prior Authorization Demo projectproject Starts : (September 4, 2012) for any order received on or after this dateStarts : (September 4, 2012) for any order received on or after this date

PMDs and POVs in group 1, 2,3,4 and 5PMDs and POVs in group 1, 2,3,4 and 5 All povs K0800-K0805 and K0809-K0812All povs K0800-K0805 and K0809-K0812 All standard power grp 1 & 2 K0813 – K0829All standard power grp 1 & 2 K0813 – K0829 All grp 2 complex K0835 – K0843 *** NOTE*** these can All grp 2 complex K0835 – K0843 *** NOTE*** these can

also go to ADMC so make sure you do PA or you will lose also go to ADMC so make sure you do PA or you will lose 25%25%

All grp 3 complex without power options K0848 –K0855All grp 3 complex without power options K0848 –K0855 All Ped and grp 4 pwcs K0887 – K0891 All Ped and grp 4 pwcs K0887 – K0891 (NOTE does not mean grp 4s are covered may help with (NOTE does not mean grp 4s are covered may help with

going to a secondary payer source.going to a secondary payer source. Miscellaneous pwcs K0898 Miscellaneous pwcs K0898 EXCLUDED are grp 3s (K0856-K0864) but these can still go EXCLUDED are grp 3s (K0856-K0864) but these can still go

to ADMC in all jurisdictions. to ADMC in all jurisdictions. Pademo@cms.hhs.gov for more information for for more information for

documentation help go to usrehab.com and PMD help from documentation help go to usrehab.com and PMD help from PeggyPeggy

CMS PMD Demo (submit)CMS PMD Demo (submit) F2F documentationF2F documentation 7 element order7 element order Detailed Product DescriptionDetailed Product Description Any other relevant documentation if Any other relevant documentation if

necessary necessary Suggest sending any relevant Suggest sending any relevant

documentation that shows continued documentation that shows continued progression of disease state especially progression of disease state especially for cardio / pulmonary disease / for cardio / pulmonary disease / conditions.conditions.

Keep a check off sheet for what is required Make sure all staff are aware of changes and dates The 45 days is how long the “ordering practitioner”

has to get the information to your office. You must have date stamp/or similar for receipt Have 120 days from F2F to deliver chair Timing starts at original F2F or when ordering

practitioner reviews the PT/OT evaluation PT evaluation does not exempt F2F **** Make sure any changes/updates are relayed to all

staff

To do a “free” upgrade use the code the patient meets criteria for than and than put RRKHKXGL in the narrative field and explain what you are doing

Bill code provided: K0816RRKHKXGL then in narrative state K0823 provided because this is all we had in stock on this date (why gave free upgrade)

Beneficiary Requested upgrade:RRKHGA (1st line) and narrative explaining this is the base

pt. {WANTS}- will deny-RRKHKXGK (2nd line) narrative field note this is the item the

patient meets criteria for {NEEDS}KB is the overflow modifier when using an ABN –99 if you need greater than 4 modifiers and no ABN being

used. (most often used for purchased replacement bases or accessories with RTLT modifiers)

BOTH CODES CAN BE PUT ON DPD AND CLEARLY IDENTIFY EACH CODE (MORE IS SOMETIMES BETTER)

IMPORTANT LCA IMPORTANT LCA (least costly (least costly alternative)alternative) February 4, 2011 the LCA became affective --- March 14th –

items Group 2 (K0806/K0807(POVs***) & K0830/K0831(PWCs) & Group 4 PMDs*** fell into statutorily non covered in the LCA and ***** CHANGED Back on June 1, 2011 with July Revision to LCD POLICY****

This meant basically that if you tried to do an upgrade with an ABN these items would deny with an ANSI 96 so there would be no reimbursement from Medicare for a base with a seat elevator.

The ansi denial would be on both lines because you could not use a GA and would have to use a GY modifier on first line.

This is a rule that the 4 jurisdictions have no control over. Industry associations are aware and are working along with US Rehab/VGM/NCART/AAH/ to try to address this through regulatory channels.*** SUCCESS*** Corrected as of 6/1/2011

The PMD LCD will be revised as of June 1, 2011 to allow for an upgrade for Grp 4 to Grp 3 PMDs and

CAUTION – Grp 2 POVs to Grp 1 POVs – remember has to be needed (for use) within the home – VERY rarely that a grp 2 POV could actually go throughout someone’s entire home

1. 5/5/2005 – MAE was published by CMS with implementation July 5, 2005 2. MAE relates to MRADL (mobility related activities of daily living) 3. August 24, 2005 – CMS issues regulations that CMNs no longer required for Power w/cs and

POVs 4. September 14, 2005 – Evidence of Medical necessity – PMD claims 5. **No CMN required for Manual Sept 23** 6. transitional CMNs 10/01/05till {4/1/06} Face 2 Face - 10/25/05 (45d grace existing pts.) 3/10/06 // 30ds – detailed order(7 element order) (1/1/06-4/1/06)not req. (F 2 F still) 3/31/06 IFR fact sheet *45d* - NOTE date Federal Register 4/5/06–will be final in 60days*6/05/06* implementation Date STAMP/or equivalent doc. MD --- 6/5/06 7/11/06 updates – 120 days (p F2F) deliver chair (8/24/06) Detailed order must include brief description of base, options to be billed – your charge and

Medicare allow / or N/A *8/24/06* (HCPCs Code) **DATE – AFTER 7 element order** Sign attestation that you have no financial involvement with PT/OT 8-10-06 April 1, 2008 – ATS / ATP must be “employed by” supplier completing evaluation on the patient

– (ATP requirement for clinician eval. removed from policy (12/07) – The ATS must be personally involved in actual eval and not just review paper work – Qualified technician for repairs in new Quality Standards --- Keep copy of ATS Resna exam letter on file & Rehab contact “form” or statement showing direct involvement

KX modifier required date of service on or after 11/15//2006 NUKHBPKX – if >4 mods. Req. NUKHBPKB (if ABN used) 99 if replacement modifier needed and

put extra modifiers in HAO record & explain use October 1, 2009 – must detail out each accessory on detailed order (make/model) MUST have legible signatures ---October 2009 – physicians name can be printed below/typed November 5 2009 – 7 element order –no reference to PMD/PWC/Scooter within body of the

order (may be “leading” physicians to order power mobility) 1/1/2011 – pwcs K0813-K0831 and K0898 go into capped rental / accessories bill same as

before Competitive bid started on 1/1/2011 (group 2 standard power /grp. 2 complex rehab are part of) June 2011 – No pricing required on detailed written order Retro active to Oct 2009

Time lines and revisions 2011 (2)Time lines and revisions 2011 (2)2012 big is PA change2012 big is PA change

February 4, 2011 the LCA became effective --- March 14th – items Group 2 (K0806/K0807(POVs***) & K0830/K0831(PWCs) & Group 4 PMDs*** fell into statutorily non covered in the LCA and ***** CHANGED Back on June 1, 2011 with July Revision to LCD POLICY****

Manf chair that has both a captain seat code and rehab seat code such as K0822 – can’t bill essential cushion and back – both chair and cushion will deny since CMS states that if they need rehab seating it would be specialty seating only. A captain seat would be comparable to an essential seat and essential back. Used to have medical necessity reasoning now has statutorily non-covered reasoning so will cause both the base and cushion to deny.

WATCH for updates and changes on these. --- Hopefully

2012 update -- Prior authorization demo project started in CA-FL-NY-NC-MI-IL and TX October 2012

Timelines and revisions Timelines and revisions 20132013 KY modifier for accessories for NON-CB complex KY modifier for accessories for NON-CB complex

group 3 accessoriesgroup 3 accessories KE for mwc accessories for complex manual tilts KE for mwc accessories for complex manual tilts

and ultra light weights (K0005 and E1161) and ultra light weights (K0005 and E1161) Effective/revision dates 7/1/2013 change request Effective/revision dates 7/1/2013 change request

8181 dated 2/8/20148181 dated 2/8/2014 K0005/ E1161 –ATP and clinician required K0005/ E1161 –ATP and clinician required

3/1/20133/1/2013 JULY 1, 2013 F2F IMPLEMENTED FOR OTHER DME JULY 1, 2013 F2F IMPLEMENTED FOR OTHER DME

ITEMS PMD RULES AND ORDERS REMAIN THE ITEMS PMD RULES AND ORDERS REMAIN THE SAME SAME

Belts(E0978) Battery chargers(E2366) Complete set of tires and casters (any

type) Controller & input devices***NOTE*** if a

code specifies an expandable controller as an option (but not a requirement) at the time of initial issue, it may be billed separately (if medically necessary)

Leg rests (ELRs separate) Fixed/swing away detachable foot

rests/include ang. Adj. Weight specific components according to

sub division

Armrests (hgt. adj. will still be separate) ** except part of tilt recline code for high end pwcs)

Upholstery

Basic Equipment PackageBasic Equipment Package

Shoulder harness/straps/vest may be billed separately

Seat width/depth exceptions : grp 3 & 4 pwcs with a sling/solid/back can bill separately for:

*standard –seat w/d > 20 inches *heavy duty – w/d > 22 inches *Very HD – w/d > 24 inches *Extra HD – no separate billing

* Back width exceptions: grp 3 & 4 pwcs with sling/solid seat/back can bill separately for: *standard – width > 20 inches *HD – width > 22 inches *VHD – width > 24 inches

*Extra heavy duty – no separate billing K0108 is code to use for width/depth making sure you

give name, make, model and MSRP in narrative. Adj angle foot plates can be billed on grp 3-4 & 5 on

initial issue.

Basic Equipment PackageBasic Equipment Package

All power will have to be coded by the SADMERC 10/01/2006 (NOW DMEPDAC)

64 codes 6 groups Groups are broken out by performance Sub divisions based on wgt capacity & power

seating capability Manufacturers will submit bases for codes ****NOTE**** SADMERC was no longer

contracted by PGBA after August 18, 2008 – Noridian took over this contract {www.dmepdac.com} they are to maintain a DMECs site.

Is exactly the same as previous SADMERC site with same search features etc.

PDAC - Pricing Data Analysis Contractor

Evaluation – Mobility Assist Equipment HISTORY/DIAGNOSIS/PROGNOSIS:

_______ is a ____ yr old male/female with a diagnosis of ____. Pertinent Medical history includes ________. He/she is ___tall & weight _____. Prognosis poor, good, fair etc.

Assistance: He/she lives in a w/c accessible/non-accessible (will remodel) house/apartment

alone/with____. He/she has assistance/no assistance. Caregiver is able/unable to assist with ____

HOW NEEDS ARE MET TO DATE: Presently using a ______ that is ____ years old & in (fair, poor, good)

condition. A change is needed because: _____________________________. MOBILITY: ___ is (non-ambulatory - ambulates short distances with assistance of - etc.) high risk of falls? STRENGTH, FUNCTIONAL LEVEL & ADLS: Patient is

dependent/independent/requires minimal/maximal assist with bathing, dressing, toileting, preparing simple meals etc. Upper extremity strength is ____ Lower extremity strength ___. Movement of extremities _____. Passive range of motion _____ upper & lower extremities. Sitting balance is _____ static & ____ dynamic. Circulation ___ .

COGNITIVE ABILITY: Alert - oriented - MR - decreased cognitive status etc. Compliance with use of equipment? Safety Awareness / in home trial with MAE – must be completed for all power

chairs. *** manual can be a verbal/telephone interview with patient or family member/caregiver but should be followed up*** If the manual chair being provided is needed specifically as related to environment than an actual visual evaluation would have to be completed by suppler***

PREDOMINANT TONAL PATTERNS: Spasticity lower extremities - etc. POSTURAL IMPAIRMENT: Mr./Mrs. /Ms sits with fixed kyphosis, scoliosis,

wind swept etc. – Contractures of _____ etc.

PT/OT Evaluation Example p1

SKIN CONDITION: History of decubi rt. ischeal - no break down - etc.VISUAL/HEARING: Presents with limited vision - WNL - Hearing WNL etc.PLANNED USE FOR CHAIR: What are patients daily activities that they require this level of

chair? This is specific as related to MRADLs.CAREGIVERS’S CONCERNS: Who was involved in evaluation? What do they see as needs for

their family member, patient, friend? How available are they? Time spent with patient _______. Are they available & willing to assist patient with care of base being provided?

Risk to patient (injury) – history of frequent falls (be specific) One fall a year would not be something that would be acceptable.

ESTIMATED NUMBER OF YEARS CHAIR WILL BE USED/ FUTURE NEEDS ADDRESSED: Permanently / will they need an add on at a later date? Prognosis is very important when choosing specific bases because of need for future changes to meet functional decline.

Evaluators’ names & titles. --- PT/OT/ATPS etc.The next part is to be completed with ATP assistance as needed. It is important that all

accessories that are required for the seating and positioning needs of the client have the functional needs documented

EVALUTION for specific equipment & Accessories (example)

Equipment (base) & explanation of need for specific accessories.Base - Name, make, model no. - Why this base is needed above any lower level chair for

functional mobility within the home.Tilt/Recline: Name, Make, Model no - What is the condition that requires this specialty item.

What was used in past? Why is change needed?Seat - Special width/depth (name, make, model of base & why this special sizing was needed).

Leg rests : If power Name, make, model & why needed - If manual why needed over regular

leg rests. (edema, fixed hip angle, cast etc.)Armrests: Adjustable height, arm troughs etc. - Why needed over standard.Other Special Considerations: Make sure you always give the name, make, model, of the

specialty item and the condition which requires the item as related to medical necessity & not convenience.

** Past history of use of same or similar equipment must always be addressed***

If you are using a special item and the standard item has an existing code for any accessory you must state why the standard item would not meet the needs of this particular patient as related to Medical Necessity & not convenience. The item must address the needs of the patient both present and future & not care givers specifically.

MEDICAID --- Additional Information Make sure that you give other options/bases (with

pricing) tried and why the other option/base did not meet the needs/goals for the particular client/patient. Use Medicaid codes as required. (This is good to use with Medicare as well.)

In many states Medicaid wants more detailed information on products such as breaking out the hardware from specific items and giving Medical Necessity for this as well. ie: Laterals – Hardware to attach laterals. (why detachable/swing away needed over fixed hardware)

NOTE Check off sheets are OK IF the answer is explained within the notes or beside the check off. E.g. (weak UE Y NO) should explain what weakness is related to.

What is “intended” as a meaning and what is actually documented is a difference in actual coverage.

The algorithm states that physician must address why cane – walker -manual chair will not meet needs. This needs to be addressed in all categories (even Quads) and replacement bases with the

completion of the F2F (includes therapists evaluation)

F2F date means F2F date and not “appointment date” date seen etc.

The progress notes must address that patient is in for an evaluation for mobility (not follow up of multiple medical problems; for surgery etc.) *NO supplier generated FORMS*

7 element order must be dated prior to the detailed product description (suppler must receive this order before they can complete the detailed product description)

HTTP://www.dmepdac.com Coding information

A Group 2 single power option or multiple power option PWC, any Group 3 or Group 4 PWC, or a push rim activated power assist device for a manual wheelchair must be provided by a supplier that employs a RESNA-certified Assistive Technology Practitioner (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient.

*** K0005 /E1161 & any pediatric tilts as well March 1, 2011

ATP Resna Certified – you have a certification letter that states you have passed the exam – that will become part of the process of a request for documentation on an audit situation.

The person who works directly with the client in either a wheel chair “team” clinic situation/ does the equipment evaluation and documents what he/she does during the process would meet the policy statement.

The key is “documents” how he/she is involved with the selection of the particular equipment for the particular patient.

Most /ATP have a format that they use for documenting how they decide the specific base and accessories for the individual patient. The patients’ physical limitations, as described by the clinical (LCMP) evaluation, will drive the need for specific accessories and the base which, with complex rehab equipment, is a requirement.

*** The KX modifier on the claim indicates that all criteria in policy has been met so this would not be requested for billing purposes.***

Send in a copy of the ATP/RESNA certification letter for the ATS completing the evaluation on the client.

Send in the specification/evaluation summary that the ATP completes in whatever format you use to document how the specific base and accessories were chosen for the particular patient and why.

The documentation that “clearly outlines the ATP’s direct involvement with the equipment selection process” is what they are looking for. The purpose of having an ATS is to ensure that the patient receives the proper equipment to meet their needs for mobility and seating within their usual environment. So the home evaluation would also be an important part of the ATPs’ documentation.

Make sure that the signatures are legible & identify the person as an ATP. ****All documentation should be legible.****

I do not advise any types of “cookie cutter” formatting; if you have a line to complete you should complete it or put N/A; “if” you have blocks that have to be checked off than make sure these are addressed. Just something that says YES ____ NO _____ for a specific item should fully define why.

Example: laterals needed YES X NO ______ -- Why needed ___________

Do not leave it for a reviewer/auditor to have to search for the reason.

EVALUTION / SPECIFICATION Base - Name, make, model no. - Why this base is needed above any lower

level chair for functional mobility within the home. Why was this base chosen over other bases?

Tilt and/or Recline: Name, Make, Model no - What is the condition that requires this specialty item. What was used in past? Why is change needed? Make sure you clearly indicate why the specific item was chosen. Why both tilt and recline and why just the tilt or recline would not meet needs. Reference the LCMPs evaluation for additional clinical documentation.

Seating - Special width/depth (name, make, model of base & why special sizing was needed). Need height and weight – specific measurements, which is already part of your specification sheet. {Back – Cushions – Laterals}

Leg rests : If power Name, make, model & why needed - If manual why needed over regular leg rests. (edema, fixed hip angle, cast etc.)

Armrests: Adjustable height, arm troughs etc. - Why needed over standard.

Other Special Considerations: Custom foot boxes/ specialty items -- Make sure you always give the name, make, model, of the specialty item and the condition which requires the item as related to medical necessity & not convenience.

****Any accessories MUST address medical necessity.****

***Just signing off on the LCMP is not adequate unless the actual documentation within the LCMP states that (specific name, ATS) was present and involved with the selection of the specified equipment and accessories for the client.***

The critical part of any audit is legible documentation relating to the specific detailed involvement of the ATS/CRTS/ATP in the “selection of the equipment”.

K0856- K0864 & related accessories.

MEMO from : CMS dated 19 May 2008 COMPETETIVE Delayed 18 months but 9.5% decrease in allowablefor all round one products to start 1/1/2009 – even though

complexRehab did get the exempt from the CB we did not get it exemptedfrom the cut. You can’t use the KE modifier on accessories in

Group3 products --

Industry is attempting to change this.

REPAIRS – the codes that are part of the CB will have to bereplaced / repaired by a CB contracted supplier.

(this has been updated to state any one can repair but only receive CB

pricing for the item) THESE are denying --

ISSUES STILL EXIST WITH REPAIRS OCTOBER 2013

Bid winners will continue to be able to purchase group 2 standard PWCs BUT ONLY IN ROUND 1 ROUND 2 THEY ARE NOW

RENTAL FOR THE BID WINNERS AS WELL

“For any DMEPOS item to be covered by Medicare, the patient’s medical record must contain sufficient documentation of the patient’s medical condition to substantiate the necessity for the type & quantity of items ordered & for the frequency of use or replacement (if applicable). -- However, neither a physician’s order nor a CMN nor a DIF nor a physician attestation statement by itself provides sufficient documentation of medical necessity, even though it is signed by the treating physician or supplier. --

Clinical Review Judgment Clinical Review Judgment This clinical review judgment involves two steps:

1. The synthesis of all submitted medical record information (e.g. progress notes, diagnostic findings, medications, nursing notes, etc.) to create a longitudinal clinical picture of the patient; and

2. The application of this clinical picture to the review criteria to determine whether the clinical requirements in the relevant policy have been met.

NOTE: Clinical review judgment does not replace poor or inadequate medical record documentation, nor is it a process that review contractors can use to override, supersede or disregard a policy requirement (policies include laws, regulations, Centers for Medicare & Medicaid (CMS) rulings, manual instructions, policy articles, national coverage decisions, and local coverage determinations).

Date:________________ Facility / Therapist: ___________________________ Last Name:_____________________ First Name:________________________ D.O.B. ____________Family Members / Caretaker Present__________________ Reason(s) for Visit: (Circle One) (Circle One) Secure New Wheelchair Power / Manual Primary / Back up Evaluate Chair for Repair Power / Manual Primary / Back up Secure Other Rehab Device _______________________________ Evaluate Other Rehab Device for Repair _______________________________ Visit Included: (check all that apply)Initial Needs Assessment Physical / Mat Evaluation Simulation Demo Equipment Order Written Review Insurance Guidelines and Process Equipment Fitting Training On Use Delivery Follow-up on Recently Delivered Equipment Repair/ Adjustment to Wheelchair Install New Parts Adjustment for Growth Time Spent: ___________ hours. Signature: _______________________Title:____________ Date:_____________ RESNA ID # {if applicable}______________________________ I certify that I am a RESNA Certified ATP who specializes in wheelchairs; I am employed by ________ and I have had direct in person involvement in the

wheelchair selection for the above patient.

***Using this does not mean an ATP does not have to complete his/her equipment evaluation***

Good Order which must include: Date of F2F – Diagnosis relating to mobility deficit – length of need -- Item being ordered (POV or Power wheelchair) *** must clearly indicate that a major reason for visit was for mobility evaluation***

Copy of progress notes on date of F2F and any ***additional notes*** that may be required to show progression of disease process. *** Especially on cardio pulmonary disease or conditions.***

Date stamped/or equal documentation which was received from the physician within 45 days of F2F (discharge from hospital, rehab facility, SNF etc.)

Home evaluation by supplier.

Detailed written order which is a brief description of each item ordered, HCPCs code, this does not require pricing as of July 1, 2010 retroactive to October 2009 and signed by the physician prior providing the chair. Date stamp required (8/24/06)

Attestation statement (8/10/06) if a PT or OT did an evaluation and it is being included in F2F documentation ** stating supplier has no financial relationship with them** If supplier is hospital owned and evaluation was completed by PT/OT employed by the hospital this is not required.

Note: the 45 days starts on date of actual F2F or when the physician has reviewed the PT/OT evaluation and signed off. The physician does not have to see the patient a second time if there was a complete F2F prior to PT/OT evaluation, but if the PT/OT evaluation was completed prior to physician seeing patient than there has to be a F2F with an eval confirming what the PT/OT evaluation states. This would become the date of F2F.

The supplier has 120 days from the date of F2F to deliver the equipment

April 1, 2008 supplier must have an ATP on staff for any group 2 single or multi power option; any group 3 or 4 and any manual with power assist and the ATP must be directly involved in the evaluation process for the equipment being provided (as of March 1. 2013 must have ATP with any K0005 or E1161s.

**** Don’t forget “routine” information – purchase option letter/delivery ticket/AOB/ etc.**** Explanation of capped rental for K0813 through K0831s

Summary of Documentation Required

Physician/ordering practitioner: Face to face evaluation of patient functional needs for power either a scooter or power wheelchair:

{Must include basic information relating to ability to perform MRADLs within the home environment}-Basically establish need by ruling out use of a cane, walker, manual wheelchair and when going to a power wheelchair (why a scooter/POV will not meet needs) Both cognitive and functional abilities need to be addressed. ***MUST*** state that the reason for visit was for mobility evaluation.

Write order: which includes the date of the face to face; length of need; diagnosis relating to impaired mobility & item being ordered which can simply state power mobility device / power wheelchair or scooter/POV sign and date /

Make sure the supplier receives the progress notes from the date of the face to face and the good order within 45 days of “completion of” face to face.

If a PT/OT evaluation is completed – review and sign off & concur with Review and sign off on suppliers “detailed product description” *** The key here is that the face to face needs to specifically be for an evaluation for power

mobility*** There is no need for completing “forms/CMNs” Just write the information in a narrative description (SOAP notes) fax a copy of the progress notes along with the good order to the supplier & review and sign off on the detailed product description and PT/OT evaluation if one is ordered.

Physical Therapist – Occupational Therapist Complete: A functional mobility assessment which address patients’ “functional” needs within the

home. It is OK to mention what they complete outside the home. The key is what is needed within the home to complete basic adls daily that could not be completed without the use of a power mobility device. This needs to be a step by step approach ruling out least costly alternative from a cane – walker- manual w/c (all levels) to a scooter to a power wheelchair.

Make sure this is detailed and legible. Keep it basic and simple Detail out each accessory and why it is Medically necessary ie: adjustable height arm rests needed

because patient is 6’3” and requires higher arm rests for upper extremity support etc. lateral supports to maintain upright position {stroke pt etc.}

The patient cognitive awareness needs to be addressed as well. Supplier – Home Environmental Evaluation Education of patient/caregiver – safe use & care of equipment Attestation statement (if PT/OT involved) Higher end needs ATP evaluation and documentation of personal involvement Completing Detailed product description for review & signature Date stamp documentation when it comes in All follow up and processing of paper work flow Make sure ABNs – purchase option letter is also completed accurately

PMD Team Responsibilities

Capped Rental PMDsCapped Rental PMDs Effective for items provided on or after January 1, 2011, standard power

wheelchairs (K0813 – K0831, K0898) must be furnished on a monthly rental basis like other capped rental durable medical equipment (DME). 

The capped rental policy will follow the same rules as all other capped rentals.

Break in service vs break in need rules remain the same. Standard capped rental rules for beginning a new rental period will apply

to power wheelchairs. Look back periods – continued need will still have to be documented if

requested. EVEN on Capped rental items. If pt moves and pwc will not fit in new home would new pwc be allowed

___ NO – based on medical change in condition only. If lost, stolen, or irreparably damaged a new replacement pwc will follow

same rules as any other DME (one incident –not “worn out” If malicious damage/culpable neglect during CR period is noted the

supplier can present information to DME MAC for investigation /if the DME MAC (in consultation with CMS) agrees that beneficiary is responsible for the damage, the supplier can charge the beneficiary.

NOTE – after the 13th month has been reached there is an old CFR discussion capped rental s and suppliers responsibility to replace within the 5 years if the item needs replacement ***

If patient abuse is proven the provider would not be held responsible.

Physicians Progress Note (EXAMPLE format)SOAP NOTE Subjective / Objective / Assessment/PlanClient:Date:Reason for visit: (evaluation for mobility)Subjective : General information from patient/caregiver/family member/case worker etc.ie: patient states has become weaker in past few months/was using a cane and a walker but has had several falls – lives alone without any assistance etc. -_________Diagnosis & Symptoms:Objective: Height, weight – ROM – Upper and lower extremity strengths – vision – cognitive status (This needs to focus on the issue of ambulation difficulties & mobility needs within the home.) Inability to use a cane, walker, manual wheelchair – can he use a scooter within his home? Does he have the ability to transfer on an off a scooter – will he need specialty seating? This can be basic information and if the physician feels the client needs a complete clinical evaluation he /she can then refer to a seating clinic / PT or OT. Mobility – patient unable to ambulate without assistance – “was pushed into office by daughter” unable to transfer to table without assist of two etc. – objective measurements - PLAN : Refer to therapist – order scooter or basic power wheelchair Than sign and date legibly – and refer to DME / HME supplierComplete 7 element order that includes – patient name – date of face to face – item being ordered (can simply state power chair or scooter) length of need and diagnosis related to mobility impairment – signature and date (print name below signature) This information needs to be received by the supplier within 45 days of completion of the Face to Face.The completion of the Face to Face date would change if a therapist evaluation was ordered and the physician then reviewed and signed off on the evaluation. This would then become the “completion” of the face to face and the physician would write the 7 element order with that date as the Face to Face date.