CMS, industry find common ground

Tuesday, August 31, 2004

WASHINGTON - CMS agrees with industry leaders that physician progress notes should not be the sole documentation used to determine whether a beneficiary qualifies for a power wheelchair.

Medicare officials made that clear during a July 16 meeting with Restore Access to Mobility Partnership, a coalition of power wheelchair providers and manufacturers

At the meeting with CMS, RAMP members discovered that a disconnect exists between how CMS thinks medical review is being conducted and how the DMERCs are actually doing it. If a physician writes a customized letter of medical necessity describing a specific patient’s condition, that should be as credible as progress notes, RAMP members said during the meeting. CMS officials agreed, said Cara Bachenheimer, vice president of government relations for Invacare, a RAMP member.

“That is real progress because for a long time the physician letters were not given a lot of weight by the DMERCs,” said Asela Cuervo, senior vice president of government relations for AAHomecare, a RAMP member.

By relying almost exclusively on progress notes, which industry watchers claim is the case, DMERC medical reviewers regularly deny claims that other documentation such as letters of medical necessity may support. Only by looking at physician-generated documents in addition to the progress notes, which are often sketchy and incomplete, can a medical reviewer get a true picture of medical necessity, say RAMP members.

At the July 16 meeting, CMS officials indicated a willingness to address the documentation issue during one of their weekly conference calls with the DMERCs. RAMP plans to follow up with CMS to see if that happens.

“I think it is something they are going to raise,” said Seth Johnson, director of government affairs at Pride Mobility, another RAMP member. “I think there is a willingness at CMS to work through these issues.”

Despite CMS’s acknowledgement that a letter of medical necessity should be considered seriously during medical review, progress notes still will play a prominent role. If the progress notes are devoid of information justifying the need for a power wheelchair, it could throw the credibility of the letter of medical necessity into doubt, Cuervo said.

Ultimately, RAMP members want CMS to sanction additional physician-generated documents that can be considered during medical review, such as PT and OT evaluations.

On another front, RAMP’s efforts at the July 16 meeting to convince CMS to relax its bed- or chair-confined coverage criteria for power wheelchairs proved less promising.

The DMERCs began strict enforcement of that criteria in December 2003 as a way to control skyrocketing utilization. Previously, a beneficiary qualified for a power wheelchair if he could not get safely around his home.

To provide more guidance on who qualifies for a power wheelchair, and hopefully better define bed- or chair-confined, CMS created the Inter-Agency Task Force. Until the task force develops additional guidance, RAMP asked CMS to drop the bed-or chair-confined criteria and revert to the earlier coverage criteria.

CMS officials declined that request.

“They said there would be no point in the task force if (CMS) jumped the gun and came out with their own guidelines,” Cuervo said.