Medicare ramps up coverage of power mobility devices
By Kerry Hunt
Q: Are changes being made to the Medicare coverage and certification requirements for the class of durable medical equipment (DME) that includes power-operated scooters and power wheelchairs?
A: Yes. In August 2005, the Centers for Medicare and Medicaid Services (CMS) published an interim final rule that outlined several changes affecting Medicare payment for power mobility devices, which include power-operated scooters and power wheelchairs. The rule also includes revisions as to who may prescribe that equipment. Although the interim final rule is open for public comment until Nov. 25, the changes took effect in October.
Q: What changes to Medicare coverage and certification have been made?
A: The CMS made several changes, some of which specifically implement provisions of the Medicare drug benefit legislation of 2003. Here are the key changes:
Removing the physician specialty requirement for prescribing power-operated scooters. Before the regulation was changed, only certain physician specialties—including physical medicine, orthopedic surgery, neurology and rheumatology—had the authority to prescribe power-operated scooters for Medicare patients. The new regulation allows all physician specialties, as well as physician assistants, nurse practitioners and clinical nurse specialists, to prescribe medically necessary power-operated scooters and power wheelchairs.
Adding a face-to-face examination requirement. The CMS now requires physicians and other treating practitioners to examine the patient face-to-face to evaluate the medical necessity of a power mobility device. Physicians and treating practitioners will be reimbursed for that face-to-face exam through the appropriate evaluation and management (E/M) code for the level of service rendered.
Replacing the certificate of medical necessity with a new submission of medical record documentation requirement. Physicians no longer have to submit a certificate of medical necessity form to be paid for prescribing power mobility devices. Instead, following the face-to-face exam, they will have to submit supporting medical record documentation that justifies their written prescription.
Implementing add-on payment for physicians and treating practitioners. The CMS is establishing a new G-code (not announced at press time) to reimburse physicians and treating practitioners for the time and resources used to complete and submit the required medical record documentation to DME suppliers.
Providers should bill the new G-code as an add-on code, in addition to the E/M code for the face-to-face exam. Payment for the G-code add-on will equal the physician fee schedule relative values for a level 1 established office visit (99211). In 2005, the national average payment for that level 1 code is $21.60.
Q: Why did the CMS eliminate the certificate of medical necessity?
A: The CMS determined that the certificate of medical necessity was not as effective as it was originally designed to be. The new requirement of submitting medical record copies as confirmation of medical necessity means physicians won't have to complete supplementary paperwork.
The CMS also hopes that eliminating the certificate of medical necessity submission requirement—and implementing both the face-to-face exam and documentation submission requirements—will reduce fraudulent billing by DME suppliers. The new regulations prohibit suppliers from delivering power mobility devices to beneficiaries without receipt of a written prescription and supporting medical record documentation.
Q: What medical record information should be submitted to the DME supplier?
A: Physicians and other treating practitioners should submit all pertinent medical record information that clearly supports the medical necessity for a power mobility device. According to the CMS, the progress note recorded during the face-to-face exam would serve as sufficient documentation of medical necessity in most cases. You must submit the supporting documentation, along with the written prescription, to the supplier within 30 days of the face-to-face exam.
Q: Is a separate face-to-face exam required for an eligible beneficiary discharged from a hospital?
A: No. Recently discharged patients do not need a separate face-to-face exam if the same physician or treating practitioner who performed the inpatient face-to-face exam issues the written prescription and the supporting documentation. The written prescription and supporting documentation must be received by the DME supplier within 30 days of the patient's discharge date.
More information on changes to the Medicare coverage requirements for power mobility devices is available at the CMS' Web site.
Kerry Hunt is a Senior Analyst in ACP's Washington office.
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