Renowned Clinician Critiques Documentation Process

Documenting medical necessity for Medicare patients requiring power mobility is a frustrating experience for homecare equipment providers, as well as physicians. Even clinicians who specialize in helping those with physical disabilities call on the Centers for Medicare and Medicaid Services (CMS) to establish a far more efficient process. Today, homecare equipment providers face new guidelines that are retroactively applied to claims that were processed months, or even years, before the standards were adopted. The ramifications are severe, with many equipment suppliers facing excessive audits, claim denials that are often overturned upon appeal and payment delays that threaten their ability to continue providing power wheelchairs to Medicare beneficiaries.

Many physicians, largely because they write only a few prescriptions each year for power wheelchairs, are confused by the process for detailing patient face-to-face examinations, and the need to provide detailed patient chart notes. Recently, Mobility Matters interviewed noted clinician, Mark R. Schmeler, PhD, OTR/L, ATP, about the documentation process. Schmeler is an Assistant Professor in the Department of Rehabilitation Science & Technology at the University of Pittsburgh with over 20 years of experience in the field.

Q. What needs to be fixed for the Medicare process of documenting medical necessity for power wheelchairs to work better for beneficiaries, clinicians, physicians and providers?
A. What's wrong is that the system was wrong for many years whereby very little if any clinical documentation was required by Medicare other than a Certificate of Medical Necessity and prescription-thus there was little accountability. Then there was a sudden surge in utilization caused by an aging population, consumer marketing that increased awareness of the benefit and pockets of fraud and abuse. In addition, technological advancements made power wheelchairs maneuverable in apartments and homes of all sizes. Patients use them to help perform daily necessities, such as grooming, going to the bathroom and preparing food. Suddenly, Medicare was under pressure to stop the freight train, so they imposed new accountability and more documentation requirements that should have been in place a long time ago. Medical records need to reflect impairment, lack of function, or inability to perform a necessary activity of daily living that could not be performed without the power wheelchair. Physicians especially never had to do this in the past, nor do most really understand the intricacies of mobility devices given there is so much else they need to understand to be good general practitioners or specialists in areas of practice not necessarily directly related to rehabilitation. It is difficult to suddenly hold physicians to a new standard when things were so lax and vague for many years.

Q. Is CMS devaluing the face-to-face examination by insisting that a patient’s chart notes show a steady deterioration of their physical capabilities over a period of years?
A. The medical record including chart notes should always reflect the findings of a face-to-face examination (i.e. office visit) based on the reason for the visit. Records should also rationalize a reason for the intervention prescribed. The reality, however, is that the documentation can only be as good as the level of understanding the physician or therapist has related to the treatment intervention. Even many physicians or therapists trained in rehabilitation have limited knowledge of power wheelchairs, let alone the complexity of the new coverage policies. The reality is that once you take the time to dissect the coverage language (which most do not have the time or desire to do), it is not that complicated - especially if you have training in rehabilitation. But suddenly, physicians are being asked for an assessment of the patient’s strength, range of motion, their function, etc. Many physicians may look at the requirements, and say, “I don't do this kind of medicine, I don't know what they're looking for.”

Physicians in this situation should be referring these cases to rehabilitation specialists such as Physiatrists and/or Occupational and Physical Therapists, since this is what we do. But the policy is not completely clear this is an appropriate and acceptable referral pathway, and there's a lot of education that needs to take place. CMS should be providing better guidance to physicians, but the government feels they are in a position whereby they cannot dictate how physicians practice and that role should be left to the professional boards. They are also probably cautious not to make the process too easy given the freight train concerns – the growing number of people who will qualify for power wheelchairs as Baby Boomers age.

Q. What are the toughest hurdles that physicians face when prescribing power wheelchairs for patients?
A. In many instances they might not know or understand the complexity of the coverage policy. It is not that we as clinicians are not smart people, it is just that there seems to be a higher level of complexity to the documentation and provision of a power wheelchair or scooter that addresses pretty obvious needs compared to other similar interventions like artificial limbs or braces.

It can also be confusing for clinicians when different homecare equipment suppliers approach the process in different ways. Some provide lots of detailed information, and even give forms to the physician that can simplify the process. But CMS has tried to impose guidelines to prevent physicians from signing documents provided by homecare suppliers. When this occurs, CMS often denies the claims, saying these forms are outside of their guidelines. But homecare suppliers cite provisions of the National Coverage Determination in their appeals and often win their cases before administrative law judges. This discrepancy must be clarified so that all of the stakeholders – patients, physicians, clinicians and homecare providers – understand the appropriate process.

Meanwhile, other homecare providers adopt a different approach, but it places more documentation burden on the clinicians. These providers don’t give much direction to the physicians and clinicians, leaving them to wade through the complicated documentation process. Oftentimes, physicians and clinicians are at a disadvantage in these circumstances because they will tend to lean towards simpler processes because we already have enough documentation burdens. Clearly, all the stakeholders would benefit from the establishment of a more concise policy that everyone agrees contains the practices to be followed.

Still, it certainly seems powered mobility has been singled out, creating a double standard. There is not as much scrutiny, for example, with lower limb prosthetics. Medicare has developed a pretty straightforward functional classification system for those who qualify for prosthetic devices. A similar policy would work well with regards to other mobility devices including powered mobility. This is also a societal value issue that has trickled into Medicare policy. Artificial limbs provide mobility, but the perception may be that they normalizes a disability more so than a power wheelchair.

I see this across all funding and service delivery models including private insurers, Medicare and the Veterans Administration. I work with veterans who have lost limbs whereby the system seems to allow them to have several artificial limbs for one leg – one for walking, one for running, one for swimming, etc. But when you ask about a wheelchair, you find that they have been provided an old, crappy folding wheelchair, yet they use the wheelchair far more than the limbs. It is not that anyone should be denied access to the limbs they need, but the same attention should be paid to the implementation of policies that allows for access to appropriate wheelchairs.

Q. Should CMS have a standardized system for documenting medical necessity?
A. They could do more in providing guidance for powered mobility, as it is not well understood in the general medical community given coverage policies were not well defined or policed in the past. But it goes back to avoiding the notion they are dictating practice – even though coverage policies in other areas actually do this indirectly. Perhaps it is a convenient loophole to hide behind to stop the freight train as I mentioned before. But at the same time, we as an industry, through our professional associations including all stakeholders, need to identify, define, and document an acceptable standard of practice for the provision of mobility devices that CMS will likely reference for future policies.

Q. How are clinicians impacted by the flaws in the current documentation process?
A. Some clinicians are shying away from performing wheelchair evaluations because the Medicare documentation process is such a burden. Frankly, clinicians may believe their time is better spent on other types of therapy. Moreover, the documentation process becomes even more burdensome when a homecare provider is worried about the Medicare reimbursement process. The patient may have an obvious need for a power wheelchair, but the homecare provider asks that the documentation be modified or redone by the clinicians so that the case is stronger. This creates added frustration and delays. Clearly, there is a considerable gap between the intent of the documentation policy and the criteria utilized by auditors who search for any small or insignificant reason to deny claims.

Q. How are Medicare beneficiaries impacted by the documentation process?
A. Patients are inconvenienced by having to make a separate trip to see a specialist or their doctor for a powered mobility device, especially since they already have a mobility impairment that makes the trip a challenge. It is not that this extra visit is a bad thing, but they may have a perception that the process is much simpler based on the marketing by providers. Perhaps the marketing should be more comprehensive and include mentions of the role of doctors or therapists in the approval process (similar to pharmaceutical company ads). CMS could also provide more readily accessible information and guidance on their website to both consumers and clinicians.

Basically there was a swing of the pendulum from one extreme to the other – vague policy with little accountability for many years to a lot more accountability and restrictive policies that has been hard to digest and implement. It may be delaying, or even preventing, Medicare patients from receiving the power wheelchairs they need.

The bottom line is this: we have a growing population of people with mobility limitations who want to remain active participants in their homes and communities. The spirit of our nation is to allow them to keep their freedom and independence and not be stuck in a nursing home. Powered mobility is an obvious viable option for many – we just need to figure out a way to provide this in a reasonable manner that ensures those who need powered mobility get it without too much burden. The government, industry, clinicians, and consumers each have a role and stake in finding this balance. CMS is certainly in the position with the most power to facilitate these changes through appropriate policy guidance.