Pennsylvania Senators seek PWC clarity

Sunday, August 14, 2005

WASHINGTON -- Two U.S. Senators from Pennsylvania turned up the heat Aug. 5 on industry demands that CMS issue clear documentation requirements for providers of power wheelchairs and scooters.

Sens. Rick Santorum and Arlen Specter addressed the letter to CMS Administrator Mark McClellan. The letter bolsters the industry's request for clear guidance that leaves little subjective interpretation by DMERC claims processors. This uncertainty makes it difficult, providers say, to determine when a claim will be approved and has led to overly restrictive denials.

"That fact that we are still waiting for guidance on documentation is a concern shared by members of Congress," said Seth Johnson, Pride Mobility's director of government affairs. "Their points are right on the mark."

In their letter, the senators noted that the DMERCs are inconsistent about what type of documentation they want to see in a claims audit.

They added: "In addition, providers are faced with the DMERCs placing extreme emphasis on a physician's chart notes to justify medical necessity, even though physicians do not routinely document medical information in their charts to the level of the specificity that the DMERCs are requiring.

"We therefore believe that evaluations from other healthcare clinicians or letters of medical necessity from the patient's ordering practitioner should be considered part of the medical record utilized by claims processors in the event of an audit," the senators wrote.

CMS is expected to shortly release a new CMN for wheelchairs, a new POV policy and a final face-face rule. Nevertheless, the senators wrote: "We are concerned that these regulations may not provide the detailed instructions necessary to serve as a definitive determinate of medical necessity absent fraud."