More than CMN

Saturday, July 31, 2004

Editor, HME News

Applaud U.S. District Court Judge Lawrence Karlton for thrusting the CMN problem to center-stage. But don’t get too giddy about a world in which medical necessity is entirely contained within the existing CMN, or even a revision of the current CMN.

Karlton ruled that CMS can’t require anything other than the CMN to justify medical necessity. In other words, don’t ask for chart notes or progress notes written by a physician.

Worth repeating here is this caveat from one government insider: “[That’s] like telling the IRS they can only use what someone puts on the Form 1040 as the basis of their tax liability and not check any supporting documents.”

If this were a perfect world, and this were an industry that had better safeguards against fraud and abuse, the CMN would be all that’s necessary. But one has to look only as far as Houston’s Wheeler Dealer fiasco to envision a situation gone haywire.

This industry really doesn’t want the buck to stop on the CMN. It does want CMS to recognize the magnitude of the problem spawned by an insistence that suppliers make a physician’s chart notes and progress notes available to auditors.

Suppliers have no control over a physician’s record-keeping. “[They] are at the mercy of physicians,” said Cara Bachenheimer, a leader in the Restore Access to Mobility Partnership (RAMP) coalition. “And those records don’t always contain the verbiage that CMS requires to justify medical necessity.”

As this issue was going to press, RAMP was preparing for a July 16 meeting with CMS. At that meeting, RAMP planned to ask CMS to add policy language to its Program Integrity Manual that acknowledges the inherent problems underscored by the California CMN case.

“In determining whether medical necessity is met, the DMERCs are to review and treat all physician-signed documentation containing medical information about a beneficiary, not just the patient’s medical record. These documents may be prepared by other healthcare professionals involved in the patient’s care, and may include, for example, PT/OT evaluations, physician letters of medical necessity, or physician evaluations.”

The DMERCs prefer to work from the medical record - from documents generated before the patient obtains a K0011. And they may not be amenable to a physician’s “letter of medical necessity.”

But there has to be some give at CMS and the DMERCs on this issue. There must be some recognition that the current level of reliance on progress notes is a significant part of the problem. And that physicians are not always the best arbiters of a patient’s need.

RAMP is also recommending that CMS require a licensed clinician to conduct a detailed evaluation of the patient’s condition. How can this not be preferable to scouring progress notes for a scintilla of evidence that justifies medical necessity?