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Mobility and Beyond Community Forum update to assist with training of your referral sources F2F required July 1, 2013 IMPLEMENTATION WAS NOT DELAYED Actively.

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Presentation on theme: "Mobility and Beyond Community Forum update to assist with training of your referral sources F2F required July 1, 2013 IMPLEMENTATION WAS NOT DELAYED Actively."— Presentation transcript:

1 Mobility and Beyond Community Forum update to assist with training of your referral sources F2F required July 1, 2013 IMPLEMENTATION WAS NOT DELAYED Actively reviewing delayed till 10/1/2013 9/1/2013 actively reviewing delayed again till “A” date in 2014 Actively auditing for WOPD 1/1/2014 updated 1/28/14

2 A Brief outline for referral sources Peggy Walker, RN Ronda Buhrmester US Rehab/VGM fax fax 5/5/20152

3 Medicare What Works? Updates MAE In all instances for any type of DME the medical records must contain information which supports the medical necessity of the item ordered. Medical records could also be PT/OT evaluations; home health records; hospital discharge summaries; rehab hospital notes; Nursing home records etc. **The physician/Physicians’ assistant/ Licensed Nurse Practitioner who is caring for the patient & has their own NPI number can write & sign orders, complete & sign CMNs (Certificates of Medical Necessity) for documentation of medical necessity for equipment they feel the patient is in need of. (F2F implemented 7/1/2013 physician must review and sign off on PA/LNP/CNS) Progress notes *PRIOR TO PROVIDING THE EQUIPMENT* ** Medical equipment is covered for in home use and there are specific requirements of documentation for payment to be received.** IF IT IS NOT DOCUMENTED IT IS NOT COVERED! NOTE – Bathroom Equipment is not covered (anything that goes through the bathroom door) by Medicare Medicare will pay for what the patient actually needs for functional mobility within the home (they do not pay for prevention) exception being overlays for support surfaces. 5/5/20153

4 Canes/Crutches/Walkers Mobility follows an algorithmic approach in which each item has to be justified by ruling out the lower level item (the face to face requirements affects all manual wheelchairs as of 7/1/2013) Canes/crutches are covered when prescribed by a ordering practitioner for a patient with a condition causing impaired ambulation and when there is a potential for ambulation. A white cane for a blind person is non-covered since it is a “self help” item. Walkers - Standard walker is covered if prescribed by physician for a patient with a medical condition impairing ambulation & there is a potential for ambulation, AND there is a need for greater stability and security than provided by cane or crutches. Heavy duty walker E0148; E0149 is covered for patients who meet coverage criteria for a standard walker AND who weigh greater than 300 pounds. Use KX modifier. E Heavy duty, multiple braking system, variable wheel resistance walker is covered for patients who meet criteria for a standard walker AND who are unable to use a standard walker due to a severe neurologic disorder or other condition causing the restricted use of one hand. (Obesity by itself is not sufficient reason for an E0147 walker) Manufacturers, name, make, model & note or other documentation from physician detailing functional limitations which preclude the pt. using another type wheeled walker & diagnosis causing this limitation. Enhancement accessories of walkers will be denied as non-covered. Leg extensions are covered for patients 6 feet tall or more. The supplier must use specific modifiers for certain items if weight specific items are required the supplier needs to have a “documented” weight in the actual medical records- It is very important for referral sources to understand that in obesity Medicare covers according to WEIGHT AND NOT MEASUREMENTS **IF not Documented it is not covered*** 5/5/20154

5 Manual Wheelchairs Note F2F & WOPD affects all mwcs 7/1/13 What is the mobility impairment that prevents the patient from ambulating within the home? (Diagnosis) Why a cane or walker can not meet the patients’ needs within the home. When going from a lower level base to a higher level base such as from a standard manual w/c to a light weight additional information would be needed. Why patient is unable to self propel a standard manual w/c within the home – that they can self propel the K0003 (light weight) *** Note*** this can be related to information conveyed to the physician by even the supplier if diagnosis & condition would back up the statement – ie: the supplier tries the patient in a standard manual wheelchair and they could not self propel because it was too heavy for them but when they tried the (K0003) light weight w/c the patient could self propel. The medical records established need for a manual w/c. The K0003 is a base that the patient themselves have to be able to self propel and not for caregiver to be able to transfer to car. (light weight) The K0004 is covered if there is a need for a seat width, seat depth, seat to floor height or back height adjustability not available in “ANY” lower level base and patient spends at least 2 hours a day in chair and it will be needed long term. >3 months (high strength light weight) Not for basic post op patients. OR the patient is highly active and spends 2 hour or > up in chair per day. The K0005 has to be able to self propel/ highly active/ what is avail. on K-5 that is “NOT” avail. on K0004 *** This is a MUST*** ADMC available {ultra light weight} full time mwc user – MRADLs both inside and outside the home– need for maximal axle adjustability / camber/ back adj etc. The K0006 is heavy duty – needs manual base – weight >250#s K0007 – extra heavy duty – needs manual base – wgt >300#s K0009 – other w/c base – can’t use any lower level base & why (mostly bariatric) E1161 (adult) manual tilt in space – why standard with recline will not meet needs – specific to weight shifts and specialty positioning needs. Pediatric tilts can be billed to Medicare E1231 – E1234 ADMC available TRANSPORTER chair s are covered “in lieu of” (instead of standard MWC) must meet need for mobility within the home / can’t use a cane or walker – *** All MANUAL WHEELCHAIRS MUST HAVE F2F DOCUMENTATION AND WOPD ***PRIOR TO DELIVERY*** WITH ACTIVE AUDITING OF THE WOPD STARTING 1/1/14 BUT CAN GO BACK TO 7/1/13*** DMEMACS 5/5/20155

6 Bedside commodes/patient lifts (hoyers ’)/ seat lift mechanisms Bedside commodes are only covered if the patient is room confined or unable to get to toilet facilities. (Not covered to be placed over the commode in the bathroom.) (need has to be documented) Heavy duty commodes width =to or > than 23 inches – weight capacity 300 pounds or more. Detachable arms are covered when used to facilitate transferring the patient or if the patient has a body configuration that requires extra width. *any commode* **** supplier must have documentation on file as to why patient is room confined or unable to access toilet facilities*** NOT covered to fit over commode in bathroom. Patient lifts (Hoyer or other types) - covered if transfer between bed and a chair, wheelchair, or commode requires the assistance of more than one person and, without the use of a lift, the patient would be bed confined. *** KX*** is required Lift Chairs - Patient must be able to ambulate once standing (cannot be used in conjunction with a w/c or POV (must be non-amb. with these) F2F RULES APPLY** Have severe arthritis of hip or knee or have severe neuromuscular disease. Diagnosis required Must be a part of the physicians’ course of treatment and be prescribed to effect improvement, or arrest or retard deterioration in the patients’ cond. Pt. must be completely incapable of standing up from any chair in his/her home. ( The fact that a patient has difficulty or is even incapable of getting up from a chair, particularly a low chair, is not sufficient justification for a seat lift mechanism. Almost all patients who are capable of ambulating can get out of an ordinary chair if the seat height is appropriate and the chair has arms.) Once standing, the patient must have the ability to ambulate 5/5/20156

7 POVs(scooter)-**Hospital Bed** *** Note effective Pillows / wedges ruled out / considered no longer required. *** POVS [Scooters] F2F with ordering practitioner required The patient’s cond. is such that a scooter is required for pt. to complete MRADLS in their home. {The scooter must be able to fit and be used within the home.} Not considered for coverage if just needed for outside the home only. Unable to operate a manual w/c. Capable of safely operating the controls of a POV. And can transfer safely in & out of the POV & has adequate trunk stability to be able to safely ride in the POV. Order with all 7 elements required (ordering practitioner) In home environmental evaluation required at time of or prior to delivery. (supplier) *** January 2011*** Group 2 standard pwcs (K0813-K0831 & K0898) go into capped rental but scooters will remain in purchase category. F2F RULES APPLY TO ALL HOSPITAL BEDS AS OF 7/1/13 ACTIVE AUDIT 1/1/14 WOPD CAN GO BACK TO 7/1/13 – DOCUMENTATION ACTIVE AUDITING DELAYED TILL **A** DATE IN BEDS: Must have Medical Necessity documentation (no auto down codes) If you bill fully electric it will deny and not down code 1/1/ Semi-electric -- Pt. requires positioning of the body in ways not feasible with an ordinary bed in order to alleviate pain; Requires the head of the bed to be elevated more than 30 degrees most of the time due to CHF, COPD, or problems with aspiration. **** Pillows or wedges must have been tried and failed to achieve the desired clinical outcome***NOTE THIS*** removed effective Requires traction equip. which can only be attached to a hospital bed. CMNs no longer required but Medical Necessity information must be in patients’ medical records. 5/5/20157

8 Specialty Mattresses Specialty Mattresses: Group 1 (over lays) Group 2 [pressure reducing] & grp 3 Coverage Completely immobile - i.e. Pt. cannot make changes in body position without assistance Limited mobility - ie pt. cannot independently make changes in body position significant enough to alleviate pressure. any stage pressure ulcer on the trunk or pelvis impaired nutritional status fecal or urinary incontinence altered sensory perception compromised circulatory status Group 1 (mostly over lays ) Criteria 1, or criteria 2 or 3 and at least one of 4-7. F2F applies as of 7/1/ /5/20158

9 Group 2 specialty mattress Group 2 (powered pressure reducing mattresses) (Covered if meets: Criterion 1& 2 & 3 above OR criterion 4 OR criterion 5 & 6 below.) Multiple stage II pressure ulcers located on trunk or pelvis Pt. has been on a comprehensive ulcer treatment program for at least the past month which has included the use of an appropriate group 1 support surface. The ulcers have worsened or remained the same over the past month. Large or multiple stage III or IV pressure ulcer(s) on the trunk or pelvis Recent myocutaneous flap or skin graft for a pressure ulcer on the trunk or pelvis (surgery within the past 60 days) the patient has been on a group 2 or 3 support surface immediately prior to a recent discharge from a hospital or nursing facility (discharge within the past 30 days). 5/5/20159

10 Group 3 specialty mattress {require WOPD} Group 3 (air-fluidized bed) ALL of following Stage III (full thickness tissue loss) or stage IV (deep tissue destruction) pressure sore. Bedridden or chair bound as a result of severely limited mobility. In absence of an air-fluidized bed, the patient would require institutionalization. The air-fluidized bed is ordered in writing by the patient’s attending physician based upon a comprehensive assessment and evaluation of the patient after conservative treatment has been tried without success. Treatment should generally include: Education of patient and caregiver on the prevention and/or management of pressure ulcers. Assessment by physician, nurse, or other licensed healthcare practitioner at least weekly; Appropriate turning & positioning. 5/5/201510

11 Responsibilities - Ordering Practitioner PMDS Face to face in narrative format (the way they normally chart an office visit) ***Soap Notes*** 9 points to be covered. Algorithm - A good order with the 7 elements –date of face to face can be date physician saw patient or date reviewed PT/OT for completion of F2F Review and sign off on PT/OT evaluation if needed Review and sign off detailed product description from supplier Make sure supplier receives all documentation within 45 days of the “completion of” F2F Legible signatures or print name below Make sure signature is dated. 5/5/201511

12 Physicians letter (SOAP NOTES ) Mobility Assistive Equipment As you may be aware, on May 5, 2005, CMS issued a memorandum relating to Mobility Assistive Equipment (MAE) such as canes, walkers, manual wheelchairs, scooters and power wheelchairs. This letter addresses only POVs/scooters and power wheelchairs – which are described by the term power mobility devices (PMDs). On or after 10/25/2005, for all power mobility devices a face to face examination by the ordering practitioner is required. Medicare will reimburse you for the actual face to face billed under the E & M code of 99211/99212/99213/99214 (according to level of visit) as well as a new G code [G0372- allowed amount of approximately $21.60 according to your state *** used to bill for faxing the documentation to supplier within 45 days]. During the face to face there are several areas which you would be required to address & write in your progress notes. We have included a brief summary to assist you in making sure all areas required have been addressed. The face to face eliminates all forms/CMNs previously required for the power mobility devices. The items to be addressed relates to the patients’ physical & cognitive condition and functional needs for mobility assistance “in the home”. Remember, Medicare does not pay for equipment which is only needed outside the home. This basically means that you state: why your patient is unable to ambulate in the home, why a cane, walker, or manual wheelchair would not meet the patients need for mobility within the home & you write the order for the POV/scooter or power wheelchair. The information can be part of the patients’ already existing records and you may want to send copies of previous visits to ensure the information shows the progression of the patients’ condition which requires the power wheelchair or POV/scooter. The supplier will complete an in home environmental evaluation to ensure that the patient is able to safely use the item provided. The supplier completes a detailed written order (equipment evaluation) for you to review & sign off on. You will need to send your information to the supplier within 45 days after the face to face. ***Progress (SOAP) notes*** 5/5/201512

13 Good Order Example Any Family Practice Clinic Dr. John Doe, MD Any Lane Any City, USA Ph: Fx: ==================================================== 1. Patient Name: Date: Address: 2. Date of completion of (F2F):__________________ 3. Diagnosis (s) relating to mobility impairment: _____________ 4. Length of need: _________________ 5. Mobility base required: __________________ 6. Signature:_______________ 7. Date ________________ NPI ___________ (PRINT NAME) _______________ 5/5/201513

14 PT/OT Responsibilities Clinical evaluation of patients needs within the home. Goals – be realistic about what they need to do and how they can accomplish it independently. MRADLS within the home environment Get evaluation to physician in timely manner – let supplier know it has been sent. Make sure they note that ATP was present & participated in the evaluation (if there) *** this does not mean that the ATP does not have to complete his equipment recommendations and evaluations as well**** that want “proof” of ATPs direct involvement 5/5/201514

15 Example PT/OT evaluations remember this is just an example Evaluation – Mobility Assist Equipment HISTORY/DIAGNOSIS/PROGNOSIS: ____ is a ____ yo male/female with a diagnosis of ____. Pertinent Medical history includes ________. He/she is ___tall & weight _____. Prognosis poor, good, fair etc. Assistance: He/she lives in a w/c accessible/non-accessible house alone/with____. He/she has assistance/no assistance. Caregiver is able/unable to assist with ____ Prognosis poor, good, fair etc. HOW NEEDS ARE MET TO DATE: Presently using a ______ that is ____ years old & in (fair, poor, good) condition. A change is needed because: _____________________________. MOBILITY: ***CAUTION*** REMEMBER what they can do independently!!! ___ is (non-ambulatory - ambulates short distances with assistance of - etc.) high risk of falls? STRENGTH, FUNCTIONAL LEVEL & ADLS: Patient is dependent/independent/requires minimal/maximal assist with bathing, dressing, toileting, preparing simple meals etc. Upper extremity strength is ____ Lower extremity strength ___. Movement of extremities _____. Passive range of motion _____ upper & lower extremities. Sitting balance is _____ static & ____ dynamic. Circulation ___. COGNITIVE ABILITY: Alert - oriented - MR - decreased cognitive status etc. Compliance with use of equipment? Safety Awareness / in home trial with MAE – must be completed for all power chairs. *** manual can be a verbal/telephone interview with patient or family member/caregiver but should be followed up*** If the manual chair being provided is needed specifically as related to environment than an actual visual evaluation would have to be completed by suppler*** PREDOMINANT TONAL PATTERNS: Spasticity lower extremities - etc. POSTURAL IMPAIRMENT: Mr./Mrs. /Ms sits with fixed kyphosis, scoliosis, wind swept etc. – Contractures of _____ etc. 5/5/201515

16 Evaluation p-2 specific base required --Power wheelchair / Scooter) Cushion - Name, make, model MSRP & why this is needed above a lower level cushion. What was used in past & why is change needed? (New codes 08/01/2006) Use KX modifier except on general use cushions. Back - Name, make, model no., MSRP & why this is needed above a regular sling back or planar back with 1” foam. Again what was used in the past & if changing why? (Use KX modifier except on general use and Clinical evaluation required on “custom” codes) New codes 08/01/2006 RESPIRATORY STATUS: COPD, Asthma, no problems etc. SKIN CONDITION: History of decubi rt. ischeal - no break down - etc. VISUAL/HEARING: Presents with limited vision - WNL - Hearing WNL etc. PLANNED USE FOR CHAIR: What are patients daily activities that they require this level of chair? This is specific as related to MRADLs. CAREGIVERS’S CONCERNS: Who was involved in evaluation? What do they see as needs for their family member, patient, friend? How available are they? Time spent with patient _______. Are they available & willing to assist patient with care of base being provided? Risk to patient (injury) – history of frequent falls (be specific) One fall a year would not be something that would be acceptable. ESTIMATED NUMBER OF YEARS CHAIR WILL BE USED/ FUTURE NEEDS ADDRESSED: Permanently / will they need an add on at a later date? Prognosis is very important when choosing specific bases because of need for future changes to meet functional decline. Evaluators names & titles. PT/OT/CRTS/ATS etc. EVALUTION for specific equipment (example) Equipment (base) & explanation of need for specific accessories. Frame - Name, make, model no. & MSRP - Why this frame was needed above any lower level chair. Tilt/Recline: Name, Make, Model no. & MSRP. - What is the condition that requires this specialty item. What was used in past? Why is change needed? Seat - Special width/depth (name, make, model of base & why this special sizing was needed). MSRP (if not already coded for Legrests : If power Name, make, model & MSRP & why needed - If manual why needed over regular leg rests. (edema, fixed hip angle, cast etc.) Armrests: Adjustable height, arm troughs etc. - Why needed over standard. 5/5/201516

17 Evaluation P-3 Other Special Considerations: Make sure you always give the name, make, model, MSRP of the specialty item and the condition which requires the item as related to medical necessity & not convenience. ** Past history of use of same or similar equipment must always be addressed*** If you are using a special item and the standard item has an existing code for any accessory you must state why the standard item would not meet the needs of this particular patient as related to Medical Necessity & not convenience. The item must address the needs of the patient both present and future & not care givers specifically. MEDICAID --- Additional Information Make sure that you give other options/bases (with pricing) tried and why the other option/base did not meet the needs/goals for the particular client/patient. Use Medicaid codes as required. (This is good to use with Medicare as well.) In many states Medicaid wants more detailed information on products such as breaking out the hardware from specific items and giving Medical Necessity for this as well. ie: Laterals – Hardware to attach laterals. (why detachable/swing away needed over fixed hardware) 5/5/201517

18 Suppliers Responsibilities Assist PT/OT with evaluation and equipment information Gather all information from ordering practitioner/clinicians/medical records etc. Do in home evaluation at time of/or prior to delivery (after 7 element order has been received). Detailed product description must be completed prior to delivery Date stamp all documentation received Make sure all other routine information is in chart. Attestation statement required on all group 2 single power options and above – Completion of ATP evaluation for higher end power/E1161s /K0005s ALL signatures must be legible or have printed name below = person signing delivery ticket must date signature. MAKE SURE TO GET PURCHASE OPTION LETTERVFOR ALL PURCHASED POWER WHEELCHAIRS!!! This is still required. 5/5/201518

19 IN Home Evaluation Example Environmental Assessment for Mobility Equipment ABC Company Patient Information: Name: Address: Date of Assessment: ____________Completed by:__________________ Housing Type: Apartment – Single story – two story – Mobile home etc. Comments: Surfaces: Carpet ____ Linoleum _____ Hardwood ______ other _______ Comments: Space: Cluttered: ______ Open ______ Small rooms _____ Hallways Comments: Rooms Accessible: Bedroom___ Bath___ Living/family Room __ Dining/Kitchen___ (ramps or steps?) Comments: Measurements: Entry Doors: width _______ Bathroom ______ Kitchen _____ Bedroom ______ Hallways _______ Other _______ Entrance: Ramps – steps – low threshold Outside access: paved – gravel –dirt Recommendations: Patient and/or caregiver/family member is willing and able to use the mobility device safely and adequately to assist with MRADLs in the home. Y ______ N ______ Patient and/or caregiver/family member was educated on care & safety with use of equipment. Y __ N__ He/she is able to use in the home. Y __ N ___ Patient / Caregiver: Signature ______________ Date ____________ Why patient unable to sign if caregiver signs. Suppliers Signature ______________ Date _______ Print name ____________________ 5/5/201519

20 Attestation Statement to be completed by supplier or PT/OT Company Letterhead This is to attest that ABC company has no financial relationship with (name, PT/OT) completing the evaluation for (patient name) on (date). Signature: Title: Date: NOTE: needs to be specific to patient /Clinician/date / *** WE HAVE SEEN DENIALS FOR NOT HAVING AN ATTESTATION STATEMENT RELATING TO PHYSICIANS SO JUST ADD HIS/HER NAME TO IT*** 5/5/201520

21 Detailed Product Description base & accessories requires name/make/model//number Company Name Address Phone: Fax: Patient Name: Address: Date of F2F: THIS IS START DATE OF ORDER Dear Dr. _____ in order to assist your patient in receiving the proper mobility equipment and/or specialty seating we are required by Medicare to complete a description of the base and all items we are providing to the patient for your review. Upon assessment of the needs of the patient in their usual environment we feel the following product and seating will best meet Mr/Ms/Mrs _________ functional mobility needs. If you agree please sign and date below. Eq: _____HCPCS Code_____ COMPLETE description of all accessories as well as base (name,model #) NO PRICING REQUIRED 6/1/2011 Physicians signature ______________ Date _____________ NPI _____________ Print name _____________ 5/5/201521

22 Basic Equipment package p-1 (power) Belts(E0978) Battery chargers(E2366) Complete set of tires and casters (any type) Controller & input devices***NOTE*** if a code specifies and expandable controller as an option (but not a requirement) at the time of initial issue, it may be billed separately (if medically necessary) Leg rests (ELRs separate) Fixed/swing away detachable foot rests/include ang. Adj. Weight specific components according to sub division Armrests (hgt. adj. will still be separate) Upholstery 5/5/201522

23 Basic Equipment Package p-2 Shoulder harness/straps/vest may be billed separately Seat width/depth exceptions : grp 3 & 4 pwcs with a sling/solid/back can bill separately for: *standard –seat w/d > 20 inches *heavy duty – w/d > 22 inches *Very HD – w/d > 24 inches *Extra HD – no separate billing * Back width exceptions: grp 3 & 4 pwcs with sling/solid seat/back can bill separately for: *standard – width > 20 inches *HD – width > 22 inches *VHD – width > 24 inches *Extra heavy duty – no separate billing K0108 is code to use for width/depth making sure you give name, make, model and MSRP in narrative. Adj angle foot plates can be billed on grp 3-4 & 5 on initial issue. 5/5/201523

24 Summary What is “intended” as a meaning and what is actually documented is a difference in actual coverage. The algorithm states that physician must address why a cane – walker – manual chair will not meet needs. – This needs to be addressed in all categories {even Quads} and replacement bases (except if <5yrs and destroyed by catastrophe (fire/flood/theft etc) F2F date means F2F date and not “appointment date” * new items require F2F July The progress notes must address that patient is in for an evaluation for mobility (not follow up of multiple medical problems; FU for surgery etc.) Ordering Practitioner***NO FORMS*** can not stand alone for documentation purposes *** must have good Medical necessity clinical documentation on any post pay review for any item. They will ask for previous progress notes in some instances (cardio/pulmonary diseases and conditions) A good progress notes relates to the need for the equipment being ordered and should discuss the individuals functional limitations as related to the specific equipment being ordered. Note if it is not documented it is not covered!!! 5/5/201524

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