McClellan: 'Old standard out of step with modern medical practice'

Friday, September 30, 2005

Editor's note: The following is a partial transcript of CMS Administrator Mark McClellan's press conference on the agency's plan to replace the current CMN with a physician's prescription. Also at the press conference were Kim Brandt, director of program integrity, and John Warren, a health insurance specialist in CMS's division of medical review.
McClellan: This interim final rule is part of a comprehensive strategy to help Medicare beneficiaries get the mobility assistance equipment they need while avoiding the unnecessary administrative burden and inappropriate Medicare spending. Appropriate professional evaluation and documentation in the patient's record is the key to effective use of mobility devices and the quality and continuity of care for beneficiaries.
As part of this new approach, CMS is eliminating the requirement of a certificate of medical necessity to accompany claims for power wheelchairs and scooters. In place of the CMN, the interim final rule describes the clinical documentation from a patient's clinical record to be submitted, along with a written prescription, to the supplier before the supplier delivers a power wheelchair or scooter.
We are also eliminating the restriction that allows only specialists in physical medicine, orthopedic surgery, neurology or rheumatology to prescribe power scooters. That is inconsistent with current standards of care that focus more on the need for an effective evaluation of the patient's status by the treating health professionals. This new rule allows both physician and treating practitioner to prescribe power wheelchairs or power scooters, and these actions underscore that a beneficiary's physician or treating practitioner is in the best position to evaluate and document a beneficiary's clinical condition and medical needs.
Because of the changes in the documentation that suppliers need before delivering a power wheelchair or scooter, CMS now, for the first time, authorizes additional payment to physicians and treating practitioners for preparing and providing the required documentation from the medical record to the equipment supplier.
Q: What is the reimbursement to the physician, and is there a standard form that a physician has to fill out?
McClellan: The payment is $21.60. It will be adjusted by the usual geographic factors that apply to the physician's fee schedule. Because we want this document to reflect the patient's needs, there isn't one standard form. Rather, we want to rely on the information that the physician develops in the course of doing an appropriate medical evaluation and recommendation based on the results of the evaluation, which comes straight from the medical record.
Q: What made you decide to drop the CMN for power operated vehicles and wheelchairs?
McClellan: The CMN was designed for the earlier coverage standard. We now have a clinical function standard and that function standard is best reflected by the clinical evaluation in the medical record. Important functional details in the medical record were frequently not included in earlier versions of the CMN. We think since we want to provide personalized support that reflect our beneficiary's needs and reflects the full range of power mobility devices available, that this approach of relying on the documentation that a physician or treating practitioner generally uses is the least burdensome and most effective way to achieve that goal.
Q: Does this mean that doctors are going to be responsible if they're providing documentation?
McClellan: I don't know that the doctor is assuming more responsibility for a medical necessity determination for a power mobility device. As our existing national coverage determination makes clear, the physicians is in the best position to evaluate what the beneficiary needs. That's part of standard and appropriate medical practice. The point isn't to create new burdens for physicians and other health professionals. Rather, this is an existing responsibility for health professionals, and we want to make sure we are supporting them effectively in fulfilling that medical responsibility and in getting the necessary documentation to the supplier.
Q: In the instructions you give to the doctor, will it pretty much ensure that if they follow the instructions, medical necessity will be documented appropriately?
Brandt: We are requiring information both from the physician and the supplier. Certainly, there is a little greater expectation here on the physician because of the face-to-face requirement to be providing us with even more detailed information. When they document their patient encounters, they really need to describe the patient's clinical condition. We want to hear about the patient's strength, his disease progression. It's that information that our contractors would use when making a determination as to whether to evaluate a claim for payment. When you evaluate a post-pay review, it's all of that information we would be looking for.
Q: There are a substantial number of changes in the works and a fairly aggressive time frame for implementing them. Will CMS consider extending that time frame so the industry can adjust?
McClellan: I do think that the changes we have made are important to implement as soon as we can. The old standard will be out of step with modern medical practice. The sooner that we can bring the more up-to-date evaluation based on their clinical and functional status and the access to current technology in power mobility devices that goes along with it, the better for beneficiaries. But obviously, this has to be a partnership between us and the provider and supplier communities, so we want to make sure that we're providing appropriate support and guidance along with that.
Q: As the physician's documentation is transmitted to the supplier, how does that happen, and is it subjected to carrier scrutiny every time or just in a post-payment audit?
Warren: That documentation does not need to be submitted to the DMERC with every claim that's submitted to the DMERC. It needs to be kept on file by the suppliers and provided upon DMERC request.
Q: If that's the case, when the supplier submits a claim to DMERC, he really only has to submit the prescription and then the medical documentation only when requested?
Brandt: Correct.
Q: Are you going to use gap filling to price the new 49 codes?
McClellan: We are absolutely still in the stage of taking comments on how we can set those payments and use those codes most efficiently.
Q: How do you see the final interim rule affecting utilization rates for power wheelchairs?
McClellan: I think that eliminating the specialist requirement is going to make it easier for many people who need mobility devices to get the evaluation done and get them done effectively to enable them to get the mobility support that they need. At the same time, I think the greater access and our emphasis on clinical evaluations and functional evaluations will help target the needs of these patients more effectively. So we may well see a shift in distribution of devices that are prescribed. I think the net impact may be more beneficiaries being served while also avoiding unnecessary cost from inappropriate prescriptions. I think this can be a win-win for all parties involved, particularly beneficiaries.
Q: You mean more beneficiaries will be serviced total, meaning the number of beneficiaries with power wheelchairs or scooters could well go up.
McClellan: It could well go up.
Q: Are your reviews or spot checks going to increase?
McClellan: I want to be clear that we do expect documentation from the medical record of the medical necessity of a particular product to be kept on file by each of the suppliers for all the prescriptions that they fill. They shouldn't be filling prescriptions unless they have that medical documentation. Now, we're not going to ask for that documentation as a routine matter in every case, but it definitely should be available to assist with timely and effective review. Having that information on hand when prescriptions are filled is going to help to make sure that patients get the right prescription, so we won't have a problem with mismatches between clinical need and type of clinical devices prescribed.
Q: If, in the case of post-payment audit, the medical records are requested and prove to be inadequate, will the physician pay any penalty or suffer any rebuke?
McClellan: From the standpoint of suppliers, the best guidance from us is pay close attention to the medical evaluation. We're making clear the kind of information we're looking for. It's the kind of information that's necessary to prescribe appropriately for an individual patient based on their individual needs, and we expect that documentation to be available on hand with the suppliers. If they follow the approach of taking the clinical evaluation seriously and taking the documentation seriously, they should do fine in this new approach to payment.