Ask the DMERC MDs

Wednesday, August 31, 2005

In last month's column, the DMERC Medical Directors felt it would be useful to review some of the common questions that have arisen about the Mobility Assistive Equipment NCD (NCD 280.3). We continue with some additional questions this month.
Q. Does the beneficiary always have to have a cane/walker trial before payment for a manual wheelchair would be approved or a manual wheelchair trial before power wheelchair approval?
A. The sequential approach should always be the foundation for determining the type of equipment that is medically necessary for each beneficiary. However, in individual cases where the beneficiary's condition clearly and unambiguously precludes the reasonable use of a device, it is not necessary to undertake a trial of that device for that beneficiary. In the event of an audit, the medical records would be expected to document this condition.
Q. Sometimes a doctor refuses to give me medical records. Is there a regulation that requires them to provide these records?
A. The Social Security Act (SSA) requires an entity furnishing an item or service to provide diagnostic or other medical information in order for payment to be made. The SSA requires the physician or practitioner to provide that information to the entity at the time that the item or service is ordered by the physician or practitioner.
Despite this statute, many physicians are reluctant to release medical records because of HIPAA concerns. While HIPAA requires adoption of practices to safeguard protected health information (PHI), there are exceptions for disclosure of PHI for the purposes of treatment, payment or healthcare operations. Therefore, suppliers can assure physicians that it is not a violation of HIPAA to provide a DME supplier with medical records that support the medical necessity of prescribed equipment.
Providing medical records to medical equipment suppliers falls under the disclosure of PHI for the purposes of payment. Medicare statute requires that payment only be made for items or services that are "reasonable and necessary" and payment cannot be made or confirmed without these records. Furthermore, these records may be provided without having a Business Associate Agreement with the supplier requesting the records or a release of information from the beneficiary.
Q. I have a beneficiary who is unable to walk, but the beneficiary is blind and therefore unable to safely use a manual or power wheelchair. In cases such as this, will Medicare pay for a wheelchair so a caregiver can transport the beneficiary?
A. A caregiver's need to use a wheelchair to assist the beneficiary in MRADLs may be considered in the decision to approve payment for a wheelchair.
Q. Does NCD 280.3 extend MAE coverage to include beneficiaries who need it for use outside the home?
A. All MAE items fall under the DME benefit, which stipulates that the equipment is only covered if the beneficiary needs that item for use in the home. Therefore, MAE is not covered if the beneficiary only needs it for out-of-home use.
Q. NCD 280.9 (Power Operated Vehicles That May Be Used As Wheelchairs) states that, "A specialist in physical medicine, orthopedic surgery, neurology, or rheumatology must provide an evaluation of the patient's medical and physical condition and a prescription for the vehicle to assure that the patient requires the vehicle and is capable of using it safely." Does NCD 280.3 eliminate this requirement?
A. Yes it does. Note that the requirement for a written order prior to delivery for POVs is not part of NCD 280.3 and, therefore, remains in place.
Q. If a provider uses their CRTSs to do patient evaluations for MRADLs (instead of a PT, OT, Physician or other clinician) for manual or power wheelchairs, will that constitute a clinical evaluation and will the CRTS documentation be considered credible evidence of need in event of audit?
A. Medical personnel create medical records. A CRTS is considered non-medical. Therefore, their documents are not considered part of the medical record. Thus their evaluations, while of use in documenting the specific equipment provided, would not be acceptable to document the extent of the patient's functional impairment and the impact of that impairment on ADLs.

The medical directors are Paul Hughes, M.D. (Region A), Adrian Oleck, M.D. (Region B), Robert Hoover, M.D. (Region D), Stacey Brennan, M.D. (Region C).