CMS modifies repair policy

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Tuesday, August 26, 2014

WASHINGTON – It appears HME providers will now be able to repair equipment, such as power wheelchairs, without having to find the original medical necessity documentation from the original provider, AAHomecare reports.

If Medicare paid for the base equipment initially, medical necessity for the equipment has been established, according to the association’s initial reading of new guidance from CMS on the matter.

“When reviewing DMEPOS claims for repairs, contractors shall only review for continued medical necessity of the item and necessity of the repair,” CMS states. “Contractors shall not expend resources to determine if the requirements for the initial provision of the DMEPOS item as/when it was originally ordered were met.”

The guidance applies to all DME equipment owned by Medicare beneficiaries as of Nov. 4, 2014.

CMS offered the following example in its guidance: “Even though a face-to-face encounter is required for the initial provision of certain wheelchairs, it is not needed for the repair of a wheelchair already covered and paid for by Medicare. However, documentation from the physician or treating practitioner that indicates the wheelchair being repaired continues to be medical necessary is required. For this purpose, documentation is considered timely when it is on record in the preceding 12 months, unless otherwise specified in relevant Medicare policy.”

AAHomecare heralded the guidance as a “step in the right direction toward fixing the convoluted and confusing documentation requirements.”

“From patient complaints to members of Congress, it has taken many voices to help CMS understand that the current state of medical equipment repair is unacceptable,” stated President and CEO Tom Ryan in a release.

Issues with repairs, especially for power wheelchairs and especially in the wake of competitive bidding, have been well documented by AAHomecare, People for Quality Care and even the mainstream press.

Comments

If Medicare paid for the base equipment initially, medical necessity for the equipment has been established, according to the association’s initial reading of new guidance from CMS on the matter.

"However, documentation from the physician or treating practitioner that indicates the wheelchair being repaired continues to be medically necessary is required."

These instructions do not replace or alter other longstanding instructions related to coverage and payment for reasonable and necessary repairs and maintenance and servicing of DMEPOS items.

And we know what "doumentation" that something is "medically necessary" means.  As usual, clear as mud.

“Even though a face-to-face encounter is required for the initial provision of certain wheelchairs, it is not needed for the repair of a wheelchair already covered and paid for by Medicare." 

This statement "already covered and paid for by Medicare" should really be further evaluated before taking this message/article for it's face value. There is not really a way to determine if the power wheelchair provided was one of those that was RECOUPED by Medicare. For example, there are a lot of power mobility devices that were  provided by the Scooter Store;however, due to various fradulent activities conducted by this provider some of the payments were "recouped" and this provider is now closed for business. With this being said, there is no way to determine if the powerwheelchair obtained through the Scooter Store is turelly a "covered and paid for by Medicare" item. Therefore, it is important to still determine if the patient who did receive this equipment truelly met it's inital coverage criteria.  If and when the equipment reimbursement was "recovered or recoupled" by Medicare and you continue to believe the idea that "patient has the equipment....he/she must of qualified or we don't need to verify initial medical necessity" this idea alone might lead you to the wrong path. In conclusion, if you do not confidently confirm that the patient qualified and met the initial coverage criteria, DO NOT provide the repair without an ABN (otherwise you can forget being reimbursed...as item may not be a"covered and paid for by Medicare" item. Your claim will more than likely be denied as equipment was never "covered and paid for by Medicare" to being with.