PMD claims without G codes spell trouble, OIG says

Friday, February 13, 2015

WASHINGTON – Providers shouldn’t be held responsible for power mobility device (PMD) claims without G codes, stakeholders say.

The Office of Inspector General (OIG) found that for PMD claims without a corresponding G code Medicare did not always make payments in accordance with federal requirements for the face-to-face examination of beneficiaries, according to a new report.

Of 100 sample claims without a corresponding G code, the OIG found 53 met the requirements and 47 did not.

What Martin Szmal, founder of The Mobility Consultants, doesn’t want to see is PMD providers being held responsible because a physician didn’t bill for a G code.

“That’s out of the provider’s control,” he explained. 

Based on physician interviews, the OIG concluded that many physicians are unfamiliar with both the face-to-face requirement and the G code, which was introduced by CMS in 2005 as a way for physicians to establish and document the need for a PMD.

The OIG recommended that Part B contractors educate physicians on the use of the G code and the face-to-face requirement. 

“CMS didn’t agree with that recommendation,” said Cara Bachenheimer, senior vice president of government relations for Invacare. “Medicare doesn’t want to bear the responsibility for educating the physician community and I’m not exactly sure why.”

Both Szmal and Bachenheimer fear the responsibility for educating physicians will fall squarely on the shoulders of providers.

“This question comes up several times a year: ‘When is CMS going to educate physicians?’” he said. “And the answer always seems to be, ‘Well, there’s no funding for that,’ and then CMS throws it back on the supplier to educate their own physicians.”

Even if education wasn’t an issue, Cara Bachenheimer says at $20 CMS offers physicians very little motivation to bill for a G code. 

“The payment level is so negligible that physicians probably don’t bother—not when you look at what they’re billing for an office visit,” she said.  

The OIG also recommended that CMS adjust the 47 claims representing overpayments of $115,000 and require physicians to use the G code when prescribing PMDs.


If the physician did bill the G code, there probably was a F2F exam, but the reverse isn't true. In my experience with other F2F items, a documented exam doesn't always result in a documented medical necessity anyway. Medicare is just looking for more excuses to deny claims.