Ask the DMERC MDs

On May 5, 2005, CMS released the National Coverage Determination (NCD) for Mobility Assistive Equipment (MAE). In this month's column, the DMERC Medical Directors felt it would be useful to review several of the common questions that have arisen about this NCD. Q. How does the MAE NCD change the way the medical necessity is determined? A. The NCD removes the previous "bed- or chair- confined" criterion and extends coverage of MAE to include beneficiaries who have a personal mobility deficit sufficient to impair their participation in mobility related activities of daily living (MRADLs) in the home. In addition, the NCD uses an algorithmic approach to determine coverage eligibility of MAE. Q. How are mobility related activities of daily living (MRADL) defined? A. Activities of daily living (ADLs) are activities related to personal care. MRADLs include toileting, eating, dressing, grooming, and bathing. Q. How does this algorithmic approach work? A. MAE coverage is determined by sequentially considering a series of nine questions. These questions provide the clinical guidance for the coverage of equipment to restore the beneficiary's ability to participate in MRADLs. The algorithm may be found on the DMERCs' web sites. Q. How does the NCD affect the current Local Coverage Determinations (LCDs)? A. Implementation of this NCD means that: - The basic coverage criteria contained in the "Walkers and Canes and Crutches" LCD are no longer in effect for dates of service on or after May 5, 2005. However, the provisions concerning specific items remain in effect. - The basic wheelchair coverage criteria contained in the "Manual Wheelchair Base" LCD are no longer applicable for dates of service on or after May 5, 2005.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The basic coverage criteria contained in the "Motorized/Power Wheelchair Bases" and "Power Operated Vehicles" LCDs are no longer applicable for dates of service on or after May 5, 2005. For POVs, this includes elimination of the requirement that it be ordered by one of four designated specialties. However, the other provisions of each LCD remain in effect. - The LCDs on "Wheelchair Options and Accessories" and "Wheelchair Seating and Positioning" remain in effect. - The Policy Articles for all these policies remain in effect. Q. How does the policy change affect the CMNs? A. For the present time, 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 claim adjudication. Detailed instructions may be found on the DMERC Web sites. Q. Does the new policy change any information requirements concerning MAE? A. No, the same information requirements are in place. Suppliers are reminded that, in the event of a Medical Review audit or Benefit Integrity investigation, they may be asked to provide medical records that corroborate the medical need for the item provided. The medical records should describe the patient's condition with enough details that it will allow us to apply the principles of the NCD and make an individual determination. Just repeating the phrases in the NCD is NOT sufficient Q. In the event of an audit, what kinds of information will you be looking for in the medical record? A. We will review the records, using the questions in the NCD algorithmic process, to ascertain that the level of equipment provided is of the appropriate type and complexity to restore the beneficiary's ability to participate in MRADLs and that the beneficiary and/or caregiver can safely use this equipment. --- 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).