Mark B. McClellan, M.D.
Administrator
Centers for Medicare and Medicaid Services
Department of Health and Human Services
Attention: CMS-3017-IFC
P.O. Box 8013
Baltimore, MD 21244-1850
Dear Dr. McClellan:
I am writing on behalf of the American Academy of Family Physicians (AAFP), which represents more than 94,000 family physicians and medical students nationwide. Specifically, I am writing to offer our comments on the interim final rule with comment period on “Conditions for Payment of Power Mobility Devices, including Power Wheelchairs and Power-Operated Vehicles” as published in the Federal Register on August 26, 2005.
Academy comments on the interim final rule with comment period on "Conditions for Payment of Power Mobility Devices, including Power Wheelchairs and Power-Operated Vehicles" as published in the Federal Register on August 26, 2005.
November 18, 2005
Background
The Centers for Medicare and Medicaid Services (CMS) defines power mobility devices (PMDs) as a class of wheelchairs that includes power wheelchairs and power-operated vehicles (POVs) (e.g., scooters). Historically, Medicare coverage of PMDs required a physician prescription and completion of a Certificate of Medical Necessity (CMN) by the physician and supplier. Medicare did not compensate physicians for completing and providing this paperwork. Further, Medicare limited coverage of POVs to those prescribed by specialists in physical medicine, orthopedic surgery, neurology, and rheumatology.
Section 302(a)(2) of the Medicare Modernization Act added section 1834(a)(1)(E)(iv) to the Social Security Act. It provides that payment may not be made for a covered item consisting of a motorized or power wheelchair unless a physician or a physician assistant, nurse practitioner, or clinical nurse specialist has conducted a face-to-face examination of the beneficiary and written a prescription for the item.
Section 302(a)(2) of the Medicare Modernization Act added section 1834(a)(1)(E)(iv) to the Social Security Act. It provides that payment may not be made for a covered item consisting of a motorized or power wheelchair unless a physician or a physician assistant, nurse practitioner, or clinical nurse specialist has conducted a face-to-face examination of the beneficiary and written a prescription for the item.
Provisions of the Interim Final Rule
CMS proposes to implement this statutory provision through a series of regulatory and policy changes. Those changes would impact physicians as follows.
Face-to-Face Examination
First, as required by the statute, CMS would require the prescribing physician to conduct a face-to-face examination of the beneficiary for the purpose of evaluating and treating the beneficiary for his or her medical condition and determining the medical necessity of the PMD as part of an appropriate overall treatment plan. Medicare would pay the physician for this examination through the appropriate evaluation and management (E/M) code submitted by the physician.
According to the draft local coverage determination (LCD) for PMDs proposed by the Medicare durable medical equipment (DME) regional carriers (DMERCs), the physician may refer the patient to a licensed/certified medical professional, such as a physical therapist or occupational therapist, to perform part of this face-to-face evaluation. Once the physician has received and reviewed the written report of this evaluation, the physician must see the patient and perform any additional evaluation that is needed. In this case, the report of the physician’s visit should state concurrence or any disagreement with the other evaluation, and the physician must provide the supplier with a copy of both evaluations within 30 days after the face-to-face examination with the patient.
Beneficiaries discharged from a hospital do not need to receive a separate face-to-face examination as long as the physician who performed the face-to-face examination of the beneficiary in the hospital issues a PMD prescription and supporting documentation that is received by the supplier within 30 days after the date of discharge. Also, accessories for PMDs may be ordered by the physician without conducting a face-to-face examination of the beneficiary.
According to the draft local coverage determination (LCD) for PMDs proposed by the Medicare durable medical equipment (DME) regional carriers (DMERCs), the physician may refer the patient to a licensed/certified medical professional, such as a physical therapist or occupational therapist, to perform part of this face-to-face evaluation. Once the physician has received and reviewed the written report of this evaluation, the physician must see the patient and perform any additional evaluation that is needed. In this case, the report of the physician’s visit should state concurrence or any disagreement with the other evaluation, and the physician must provide the supplier with a copy of both evaluations within 30 days after the face-to-face examination with the patient.
Beneficiaries discharged from a hospital do not need to receive a separate face-to-face examination as long as the physician who performed the face-to-face examination of the beneficiary in the hospital issues a PMD prescription and supporting documentation that is received by the supplier within 30 days after the date of discharge. Also, accessories for PMDs may be ordered by the physician without conducting a face-to-face examination of the beneficiary.
Prescription and Supporting Documentation
Second, again as required by the statute, CMS would require the physician to write a prescription that is provided to the beneficiary or supplier, and is received by the supplier within 30 days of the face-to-face examination. CMS defines a prescription as a written order completed by the physician or treating practitioner who performed the face-to-face examination. It must include the beneficiary's name, the date of the face-to-face examination, the diagnoses and conditions that the PMD is expected to modify, a description of the item, the length of need, and the physician or treating practitioner's signature and the date the prescription was written. According to the interim final rule, the description of the item is a narrative description of the specific type of PMD and may be as simple as “a power wheelchair.”
CMS would require the physician to provide supporting documentation to the DME supplier within 30 days after the face-to-face examination. This documentation is expected to include pertinent parts of the beneficiary's medical record (e.g., history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans and/or other information as may be appropriate) that support the medical necessity for the PMD.
The physician only has to provide those parts of the medical record that clearly demonstrate medical necessity for the PMD. CMS expects that the parts of the medical record selected should be sufficient to:
CMS would require the physician to provide supporting documentation to the DME supplier within 30 days after the face-to-face examination. This documentation is expected to include pertinent parts of the beneficiary's medical record (e.g., history, physical examination, diagnostic tests, summary of findings, diagnoses, treatment plans and/or other information as may be appropriate) that support the medical necessity for the PMD.
The physician only has to provide those parts of the medical record that clearly demonstrate medical necessity for the PMD. CMS expects that the parts of the medical record selected should be sufficient to:
- delineate the history of events that led to the request for the PMD;
- identify the mobility deficits to be corrected by the PMD; and
- document that:
- other treatments do not obviate the need for the PMD,
- the beneficiary lives in an environment that supports the use of the PMD, and
- the beneficiary or caregiver is capable of operating the PMD.
In most cases, CMS expects the information recorded at the face-to-face examination will be sufficient. However, there may be some cases where the physician has treated a patient for an extended period of time and the information recorded at the face-to-face examination refers to previous notes in the medical record. In this instance, those previous notes would also be needed, according to CMS.
CMS estimates that it will take physicians approximately two minutes to prepare and submit the prescription. In addition, CMS estimates it will take physicians ten minutes to collect and submit to suppliers supporting documentation from the beneficiary’s medical records which demonstrates that the item being provided is medically necessary. This includes physicians identifying parts of the medical record, having them copied, and giving them to the beneficiary with the prescription. CMS notes that in some instances, the physician may also need to submit additional information at the request of the supplier.
CMS plans to create an add-on “G” code, which would be reported in addition to the E/M code for the face-to-face examination, to compensate the physician for creating the prescription and preparing pertinent parts of the medical record for submission to the DME supplier. CMS indicates that it will set the value of this new code equivalent to that of 99211 (a level one established patient office visit), which is approximately $21.60 in 2005 (unadjusted geographically).
Lastly, CMS indicates that it is eliminating the CMN for power wheelchairs and POVs. This CMN expired in September, and according to CMS, the continued use of a CMN for power wheelchairs and POVs is no longer required.
CMS estimates that it will take physicians approximately two minutes to prepare and submit the prescription. In addition, CMS estimates it will take physicians ten minutes to collect and submit to suppliers supporting documentation from the beneficiary’s medical records which demonstrates that the item being provided is medically necessary. This includes physicians identifying parts of the medical record, having them copied, and giving them to the beneficiary with the prescription. CMS notes that in some instances, the physician may also need to submit additional information at the request of the supplier.
CMS plans to create an add-on “G” code, which would be reported in addition to the E/M code for the face-to-face examination, to compensate the physician for creating the prescription and preparing pertinent parts of the medical record for submission to the DME supplier. CMS indicates that it will set the value of this new code equivalent to that of 99211 (a level one established patient office visit), which is approximately $21.60 in 2005 (unadjusted geographically).
Lastly, CMS indicates that it is eliminating the CMN for power wheelchairs and POVs. This CMN expired in September, and according to CMS, the continued use of a CMN for power wheelchairs and POVs is no longer required.
AAFP Response
We find much for which we can commend CMS in this interim final rule but at the same time we are concerned about the physician being able to ensure that power mobility devices remain accessible to those who need them.
First, CMS is removing the longstanding regulatory provision that only a specialist in physical medicine, orthopedic surgery, neurology, and rheumatology can prescribe a POV for purposes of Medicare coverage. The AAFP has advocated for years that family physicians are also capable of determining whether or not a beneficiary needed and could use a POV. We are grateful that CMS is finally acknowledging this reality in its interim final rule.
Second, we applaud CMS for eliminating the CMN for power wheelchairs and POVs. Again, the AAFP has advocated for years for eliminating CMNs such as this, since we do not view them as adding any value to the process because they were not viewed as substantiating patient medical necessity as originally intended and they are a physician burden that only serves to facilitate Medicare payment to DME suppliers. The elimination of the CMN for power wheelchairs and POVs is welcome regulatory relief for family physicians that prescribe such DME.
Third, we welcome CMS’s plans to pay physicians for the remaining paperwork required under the interim final rules, although we believe the estimated time burden is incorrect. We believe it is fallacious for CMS to think that reviewing the patient’s chart, identifying the parts that are relevant, having them copied, and then providing them to the beneficiary and supplier will take only ten minutes. We also believe it is fallacious to think that suppliers will request additional information in only some instances. Previous experience with CMNs suggests that suppliers will routinely ask for additional information, adding to the burden estimated by CMS. Even though your estimated time burden is incorrect, we appreciate the recognition that this paperwork burden represents a cost to physicians and their practices, and we are grateful for CMS’s attempt to compensate physicians for that cost.
We believe that this interim final rule will add little, if any, additional diagnostic burden to family physicians. We agree with CMS that most family physicians already perform a face-to-face examination before prescribing a power wheelchair or POV, and the draft LCD produced by the DMERCs makes it clear that physicians may refer the patient to a licensed/certified medical professional (e.g., a physical therapist or occupational therapist) to perform part of the examination, as needed.
We are also confident that most family physicians document their patients’ need for a power wheelchair or POV before prescribing one. As such, providing pertinent parts of the patient’s medical record and other documentation to DME suppliers should not be problematic, even though we believe the burden is greater than CMS anticipates.
Whether the typical family physician’s documentation will fulfill all of CMS’s expectations for purposes of determining medical necessity is unclear, since the specifics included in the DMERCs’ LCD are in draft status. We recognize that this is an issue for DME suppliers, whose payment will depend on a DMERC’s determination of medical necessity based on the available documentation. We expect that family physicians and DME suppliers will resolve problems in this regard at a local level, and the Academy is willing to help educate its members, which will be a significant effort, regarding the expected documentation at a national level when the DMERCs’ LCD is final.
In the meantime, we appreciate the opportunity to comment on this aspect of the Medicare program.
Sincerely,
Mary E. Frank, M.D., FAAFP
Board Chair
First, CMS is removing the longstanding regulatory provision that only a specialist in physical medicine, orthopedic surgery, neurology, and rheumatology can prescribe a POV for purposes of Medicare coverage. The AAFP has advocated for years that family physicians are also capable of determining whether or not a beneficiary needed and could use a POV. We are grateful that CMS is finally acknowledging this reality in its interim final rule.
Second, we applaud CMS for eliminating the CMN for power wheelchairs and POVs. Again, the AAFP has advocated for years for eliminating CMNs such as this, since we do not view them as adding any value to the process because they were not viewed as substantiating patient medical necessity as originally intended and they are a physician burden that only serves to facilitate Medicare payment to DME suppliers. The elimination of the CMN for power wheelchairs and POVs is welcome regulatory relief for family physicians that prescribe such DME.
Third, we welcome CMS’s plans to pay physicians for the remaining paperwork required under the interim final rules, although we believe the estimated time burden is incorrect. We believe it is fallacious for CMS to think that reviewing the patient’s chart, identifying the parts that are relevant, having them copied, and then providing them to the beneficiary and supplier will take only ten minutes. We also believe it is fallacious to think that suppliers will request additional information in only some instances. Previous experience with CMNs suggests that suppliers will routinely ask for additional information, adding to the burden estimated by CMS. Even though your estimated time burden is incorrect, we appreciate the recognition that this paperwork burden represents a cost to physicians and their practices, and we are grateful for CMS’s attempt to compensate physicians for that cost.
We believe that this interim final rule will add little, if any, additional diagnostic burden to family physicians. We agree with CMS that most family physicians already perform a face-to-face examination before prescribing a power wheelchair or POV, and the draft LCD produced by the DMERCs makes it clear that physicians may refer the patient to a licensed/certified medical professional (e.g., a physical therapist or occupational therapist) to perform part of the examination, as needed.
We are also confident that most family physicians document their patients’ need for a power wheelchair or POV before prescribing one. As such, providing pertinent parts of the patient’s medical record and other documentation to DME suppliers should not be problematic, even though we believe the burden is greater than CMS anticipates.
Whether the typical family physician’s documentation will fulfill all of CMS’s expectations for purposes of determining medical necessity is unclear, since the specifics included in the DMERCs’ LCD are in draft status. We recognize that this is an issue for DME suppliers, whose payment will depend on a DMERC’s determination of medical necessity based on the available documentation. We expect that family physicians and DME suppliers will resolve problems in this regard at a local level, and the Academy is willing to help educate its members, which will be a significant effort, regarding the expected documentation at a national level when the DMERCs’ LCD is final.
In the meantime, we appreciate the opportunity to comment on this aspect of the Medicare program.
Sincerely,
Mary E. Frank, M.D., FAAFP
Board Chair
