Documentation still a major concern

Monday, January 31, 2005

WASHINGTON - In addition to issuing new coverage criteria for power wheelchairs, industry watchers have their fingers crossed that CMS will expand and clarify what documentation can be used to justify medical necessity.

It’s great that CMS’s Interagency Wheelchair Work Group has recommended that Medicare replace bed-or-chair-confined with a coverage criteria based on functional ambulation, say industry watchers.

“But as long as CMS relies on the physician progress notes to determine medical necessity, I think the provider is always at risk for claims being denied.” said Bryan Dylewski, president of Mobility Products Unlimited in Holly Hill, Fla.

Providers have long complained that DMERC claim reviewers rely almost exclusively on a doctor’s progress notes to justify a power wheelchair prescription. Unfortunately, progress notes are often sketchy and seldom provide the required information. The result has been a flood of denials during CMS’s attempt to rein in power chair utilization, say providers.

Restore Access to Mobility Partnership (RAMP) and other industry groups have lobbied CMS to determine medical necessity by reviewing all physician-generate documentation - not just progress notes.

CMS officials realized that clarifying the documentation requirement is a critical issue and have said they plan to address it, said Cara Bachenheimer, Invcare’s vice president of government relations.

Seth Johnson, Pride Mobility’s director of government affairs, said he expects CMS to address the documentation issue as part of its National Coverage Determination for wheelchairs.

“We believe, for example, that PT and OT evaluations should be accepted as well as letters of medical necessity from the physician,” said Johnson. “The DMERCs should also be looking at these to back up CMN.”