PMD documentation: Could clarification be on its way?

Sunday, July 8, 2007

WASHINGTON – There may be a silver lining to the power wheelchair probe TriCenturion announced last month: It could result in long-sought-after guidance on new documentation requirements.

CMS replaced certificates of medical necessity (CMNs) with physician prescriptions and supporting documentation in 2005. Since then, rehab providers have appealed to officials to eliminate some of the subjectivity clouding the requirements.

“There’s a wide range of interpretation of what documentation should be included for submitting claims,” said Tim Pedersen, chair of AAHomecare’s Rehab and Assistive Technology committee (RATC) and CEO of WestMed Rehab in Rapid City, S.D. “If we get some feedback based on the probe, at least we’ll know what they’re looking for.

“Of course,” he continued, “that could be a bad thing if you’re not documenting properly.”

In June, TriCenturion, the program safeguard contractor (PSC) for jurisdictions A and B, announced it was looking into K0823, a new code comparable to the old code K0011. TriCenturion stated that from Dec. 1, 2006, through March 31, 2007, K0823 accounted for more than 90% of the total allowed amount for all codes in each jurisdiction. Furthermore, the code accounted for more than 77% of the allowed amount for Group 2 in each jurisdiction.

Few rehab providers were surprised that TriCenturion elected to review K0823.

“(The K0011 and now the K0823) has always been the most commonly prescribed and paid for device,” said Mark Leita, director of public affairs for The Scooter Store.

That’s why rehab providers take issue with TriCenturion using an increase in utilization as justification for the probe.

“The codes were only put in place eight months ago, so they have nothing to compare the K0823 to,” said Seth Johnson, vice chairman of RATC and vice president of government affairs for Pride Mobility Products. “If they did compare the K0823 and K0011 codes, they’d probably find utilization is significantly lower for K0823.”

But rehab providers refrained from calling the probe “a grand witch hunt.”

“If you have progress notes and your charts are the way they should be, I wouldn’t be too concerned,” Pedersen said.

In its bulletin, TriCenturion stated: “(We believe) a proactive approach to the increased provision of HJCPCS K0823 will allow for identification of possible problems in the billing of this item. Areas of confusion can be addressed through focused education to suppliers of this item.”