RAMP to CMS: Clarify PWC documentation requirement

Sunday, March 13, 2005

March 14, 2005

WASHINGTON -- Before CMS implements new coverage criteria for power wheelchairs, it should clarify what documentation providers must furnish to prove medical necessity, Restore Access Mobility Partnership (RAMP) stated last week.
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 week.
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. This has caused the denial or delay in payment of millions of dollars in appropriate claims because of incomplete or missing chart notes when all other requirements were met, RAMP stated.
To help correct these problems, RAMP has developed three fundamental principles that should 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.
Furthermore, RAMP strongly urged CMS to base the new documentation system on the concept of an expanded CMN, which reflects the additional data elements for coverage contained in the final coverage policy. As appropriate, a companion questionnaire, physician letter or clinical evaluation can accompany the CMN. One CMN should exist for all wheelchairs and scooters, with varying additional documentation requirements depending on the level of complexity of the mobility equipment being purchased. For example, more basic items such as manual rental chairs should have lower documentation thresholds than more complex equipment, RAMP stated.
RAMP called the CMN is a reliable means of documenting the clinical judgment of a treating physician, and RAMP has developed a draft CMN that can be a starting point in helping CMS design one that can be used with the new coverage policy.
RAMP's draft CMN shows how the decision algorithm can be incorporated and its questions follow the decision-making process in determining the medical need for a particular piece of mobility equipment. It also offers a "Section E," which could be optional, but provides a model for gathering the additional information a supplier may need to show medical necessity. RAMP believes that suppliers should be able to use their own forms instead of the proposed Section E so long as the necessary information is collected. Also, Section E could be completed by a licensed clinician as long as the assessment is countersigned by the prescribing physician. The information in Section E would supplement the information provided in the CMN and provide the additional specificity to support the medical necessity of the mobility equipment in question. RAMP urges CMS to provide specific guidance as to what information should be reflected in the companion questionnaire.
Clearly, utilizing an expanded CMN is superior to collecting and interpreting vague and incomplete physician chart notes, RAMP stated.
RAMP is gravely concerned that CMS has previously felt that the physician chart notes combined with the judgment of the Medical Review staff of regional DMERCs were equal in value to the clinical intent of the beneficiary's treating physician as documented in the CMN. The reality is that physician chart notes are highly subjective, differ in detail from patient to patient, and do not always articulate a physician's full conclusions. As a result, RAMP strongly believes the most efficient and precise way to make sure that a physician's diagnosis and prescription are consistent and documented is to use a consistent and clear form for doctors to certify their conclusions. That form should be the CMN. In addition, RAMP recommends that CMS permit licensed clinicians to complete any additional documentation, as long as it is countersigned by the prescribing physicians. Such licensed clinicians could include the treating physician, nurse, physician assistant, physical therapist or occupational therapist.
Moreover, RAMP member Bryan Dylewski, CEO of Mobility Products Unlimited, maintained that suppliers must know with certainty what documentation will be accepted as a definitive determinant of medical necessity.
"We must be able to rely on a clinician's or physician's integrity and judgment," he said. "The final documentation requirements should be determinative and controlling. A clinician- completed CMN should provide the DMERCs with ample information to determine whether the beneficiary has a medical need that meets the criteria. CMS should not be allowed to request documents beyond those that are required unless they are conducting an audit or investigation."