Medicare Minute MD℠: Power Mobility Pearls for the Practicing Physician

Hello and welcome to another edition of Medicare
Minute. I’m Dr. Robert Hoover, medical director at CGS Administrators, the Jurisdiction C
DME MAC. This is another video in our series covering the highlights of the DME MAC policies,
officially called local coverage determinations or LCDs and related policy articles. This is a special joint presentation of the
DME MAC contractors. These video segments on the coverage of durable
medical equipment, prosthetics, orthotics, and supplies or DMEPOS are designed to give
the viewer an overview of the rules and regulations governing these items. It is not intended
to replace the policies and guidelines contained in the local coverage determinations or Policy
Articles. Today’s topic is power mobility devices
documentation but I’m going to address my comments to the treating physician who is
prescribing power mobility devices. So first, let’s go over some of the basic Medicare
rules. On your screen now you’ll see the basic
requirements for power mobility devices or PMDs. The term PMDs encompasses both power
wheelchairs and power operated vehicles, more commonly called scooters. In order for Medicare to provide reimbursement
to your medical equipment supplier for a power wheelchair, there are several statutory requirements
that must be met. An in-person visit, an H & P that documents their mobility limitations
and a prescription with 7 specific elements. Once the exam and prescription are completed,
the supplier must receive a copy of these documents within 45 days. Why is this examination so important? Because
Medicare takes an algorithmic approach to mobility assistive equipment. In other words,
Medicare wants healthcare providers to think in a logical progression of mobility aids
that might address a patient’s mobility needs. Will a cane resolve their mobility deficit?
How about a walker? What about an optimally configured manual
wheelchair? These are all questions to ask before moving
on to a power mobility device, whether it be a scooter or a power wheelchair. So now let’s move on to documentation – every
physician’s favorite topic. I often get questions from doctors and physician
extenders along the lines of “What am I supposed to document so that my patient can
get a wheelchair?” My response is often “What you learned in your physical diagnosis
class in medical school.” What I mean by that statement is that there
are no complicated tests you need to do or “magic words” that you need to say in
your documentation. What our reviewers look for is a history and physical examination
tailored to the patient’s specific situation. In the next couple of slides on your screen,
you’ll see some of the things that you should consider documenting as part of your mobility
examination. Again, not everything in these lists need
to be covered. For example, if your patient is currently using a mobility aid like a cane
or walker, it will be important to document what has changed in their condition such that
those devices are no longer sufficient and they now need a PMD. Obviously, if the patient
doesn’t currently use a mobility aid, that type of question wouldn’t apply. Most of these things are pretty obvious, as
I said, think back to medical school and that physical diagnosis class.
Do they have co-morbidities that limit ambulation? Do they have frequent falls and if so, under
what circumstances? Were they related to orthostatic changes, medications, throw rugs?
These are some of the things to think about in the history. Similarly, the physical exam is a targeted
physical exam. The slide on your screen has some of the commonly seen elements in a mobility
physical exam. So you see some of the common elements. Height
and weight, for example, are important to help determine what type of chair the supplier
can dispense because coverage of some types of chairs are based on patient weight.
As you see, most of these things are pretty straight-forward. The history and physical
should use as much objective information and descriptions as possible. Quantify things
in your exam. “Walked 15 yards and then stopped 5 minutes due to shortness of breath.”
Here are some examples of vague descriptions that should be avoided in documenting a mobility
exam Upper extremity weakness. Instead, grade
the muscle strength or use comparative strength statements like “Has difficulty lifting
a gallon of milk.” Similarly, “Fatigues easily” is hard to quantify but a statement
like “Has to rest or take a nap after vacuuming 3 rooms in the house” or “Has to rest
after doing even small amounts of grocery shopping” is more descriptive.
Again, the history should paint a picture of your patient’s functional abilities and
limitations on a typical day. 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. Both should contain as much objective data as possible. So what if you’re still uncomfortable doing
this kind of exam? You may elect to refer the patient to another medical professional,
such as a physical therapist as long as that individual has no financial relationship with
the wheelchair supplier. However, and this is important, you do have to personally see
the patient before or after the PT/OT evaluation. You must review the report, indicate your
agreement in writing on the report, and sign and date the report. If you do not see the
patient after the PT/OT evaluation, the date that you sign the report is considered to
be the date of completion of the face-to-face examination. So what about providing all of this information
in a form, such as those developed by the Texas or Florida Academy of Family Physicians?
Personally, I discourage the use of a form though CMS doesn’t prohibit their use. I
dislike forms because most are designed to gather selected bits of information and are
almost always insufficient. As you can see from what I described in the
history and physical information just covered, what is required by Medicare is a thorough,
FOCUSED narrative description of your patient’s current condition, past history, and pertinent
physical examination. It should clearly describe their mobility needs in the home and why a
cane, walker, or optimally configured manual wheelchair is not sufficient to meet those
needs. Most forms don’t meet this standard for documentation.
Finally, let’s talk about the prescription that you’ll need to write. As I mentioned
before, it has 7 required elements. The 7 required elements are shown on your
screen now and you, not the DME supplier, must complete this order. In other words,
the supplier cannot fill in the 7 elements and send it to you for your signature. Congress
was very specific about this when they charged CMS with developing new rules for power mobility
equipment back in 2006. You must forward a copy of the face-to-face
evaluation and your seven-element prescription to the medical equipment supplier within 45
days from the completion of the face-to-face mobility examination. You should also include
copies of previous notes, consultations with other physicians, and reports of pertinent
laboratory, x-ray, or other diagnostic tests if they will help document the severity of
your patient’s ambulatory problems. After the supplier receives your order and
the face-to-face information, they will prepare a detailed product description that describes
the items being provided including all options and accessories. You should review it and,
if you agree with what is being provided, sign, date and return it to the supplier.
If you do not agree with any part of the detailed product description, you should contact the
supplier to clarify what you want the beneficiary to receive. That does it for this edition of Medicare
Minute. As with all of CGS’ educational offerings, this is only a summary of certain
policy requirements. I encourage you to read the applicable LCD and related Policy Article
for a complete description of the coverage, coding and documentation requirements. Thank you for watching and have a nice day.

Leave a Reply

(*) Required, Your email will not be published