Increased Medicare documentation: Finding a balance

Friday, February 28, 2003

As CMS considers a change to the CMN process (see Federal Register notice, Nov. 18, 2002), I would argue that documentation in addition to the CMN must be used to determine whether a beneficiary meets the Medicare coverage criteria for a particular item. CMS needs, however, to balance the need for and use of this additional documentation with the need for DME providers to be able to operate in a climate that does not impose impossible or inconsistent burdens on providers.

Physicians have no financial or other incentive to completely document in their progress notes all information necessary for a Medicare medical necessity decision. Despite this, suppliers are held financially liable when the physician progress notes are determined by the DMERCs not to sufficiently document medical necessity consistent with the Medicare coverage rules. It is entirely unclear how much additional and corroborating information from the physician or other health care professionals involved in the patient’s care will be deemed sufficient to fully document medical necessity.

DME providers need specific guidance from CMS and the DMERCs as to the specific documentation that the DMERCs will consider sufficient in the event of a pre- or post-pay audit. To that end, we recommend the following regarding documentation beyond the CMN that should be used by CMS/DMERCs to determine medical necessity:

1. CMS needs to acknowledge that physicians commonly do not keep in their progress notes consistent information regarding all the criteria that would necessarily qualify a beneficiary for a particular item. Suppliers should be allowed to work with physicians to obtain additional evidence to document medical necessity.

2. CMS needs to provide the DMERCs with more specific guidance regarding the documentation that will be deemed sufficient to support medical necessity. In practice, the DMERCs have inconsistent requirements and make subjective judgments which impose operational difficulties on multi-region suppliers. For example, CMS should direct the DMERCs that physician-generated documentation outside the progress notes should be treated as if that documentation were in the progress notes. The key is that the physician completed this other documentation; although it may not be part of the physician progress notes.

3. When a physician has prepared a letter of medical necessity (“LMN”) or other documentation that is specific to a patient and details the reasons why the patient requires a particular item, CMS and the DMERCs should accept the LMN or other physician documentation as a statement of the patient’s actual medical condition. Oftentimes, physicians will create this LMN or other documentation and keep it in the patient record. Importantly, the DMERCs should accord the same weight to this physician LMN or other documentation as they do to physician progress notes. This approach makes sense given the reality that suppliers have no ability to ensure that physicians progress notes address all Medicare coverage criteria for a particular item.

4. When a physician orders a motorized wheelchair for a beneficiary, CMS and the DMERCs should require the physician or a physical therapist (PT) or occupational therapist (OT) or other licensed health care professional to complete a functional assessment of the beneficiary and document those findings. We agree with CMS and DMERC policy that the physician is the “gatekeeper” to DME items and services; there is no need to substitute PT/OT’s judgment in place of the physician’s medical judgement. Where, however, a physician has only limited patient information related to his/her prescription for a particular DME item, the DMERC should rely upon the more detailed evaluation of another health care professional (OT, PT, nurse, etc.).

5. The Physician Education form drafted by some of the DMERCs (and published in Supplier Manuals) was designed as a tool for suppliers to use to educate physicians about the specific Medicare coverage requirements for a particular item. In the event that a supplier provides this educational tool to a physician, the physician signs the form and states that he believes his/her patient meets the criteria, the DMERCs should give this physician-signed form as much weight as if it were directly in the physician progress notes.

The DMERCs’ should review physician progress notes to determine whether medical necessity is met. Physicians are trained to document in patient progress notes pertinent information relating to the patient. We recommend, however, that the DMERCs continue to look for medical necessity information in the physician progress notes, but in those cases in which it does not exist, the additional above-described documents mentioned (LMN, physician-signed Physician Education form, or functional assessment completed by the physician or licensed health practitioner (e.g., PT/OT, licensed nurse) should be sufficient to support medical necessity along with the CMN.

- Bryan Dylewski is president of Mobility Products Unlimited based in Holly Hill, Fla.