RAMP to CMS: Clarify PWC documentation

Thursday, March 31, 2005

WASHINGTON -- Before CMS implements new coverage criteria for power wheelchairs, it should clarify what documentation providers must furnish to prove medical necessity, according to Restore Access to Mobility Partnership (RAMP).
As part of its ongoing process to develop new coverage criteria for power wheelchairs, CMS has requested recommendations on how to craft an effective documentation process.
Last week, RAMP called the current documentation policy one of the biggest flaws in Medicare' PWC reimbursement policy. It is too often open to interpretation, resulting in DMERC claim processors increasingly insisting that physician chart notes are solely to be used to determine medical necessity, RAMP stated last month.
These physician notes vary widely in thoroughness and were never intended for this purpose. In spite of this, claim processors, who have had no personal contact with the beneficiary, often use these varying chart notes to override the clinical judgment of the physician who actually prescribed the wheelchair, RAMP stated. To help correct these problems, RAMP has proposed three fundamental principles designed to guide a new documentation policy:
- Given the complexity of the algorithm determining medical necessity in the proposed new coverage policy, CMS should acknowledge that physicians will not, as a matter of practice, document the beneficiary's medical condition with the level of specificity envisioned in the new coverage policy.
- The documentation requirements must be tied directly to the coverage policy and clearly outline the required information, who is responsible for providing the information and how the information must be documented.
- Documentation requirements must specify what documentation will be accepted as a definitive determinant of medical necessity absent fraud.