Home Health & Hospice Week

Mind the gap between NCD's effective and implementation dates.

The Centers for Medicare & Medicaid Services has ordered the durable medical equipment regional carriers to discard the old bed- or chair-confined standard for determining medical necessity for mobility assistive equipment and instead use the functional ambulation standard set forth in the May 5 National Coverage Determination.

Heads up: But a two-month difference between the policy's effective date and its implementation date could cause headaches for suppliers.

"I'm glad CMS followed through because we were hearing from DMERCs that they weren't going to apply the new coverage determination standard until they got official word from CMS," says Eric Sokol of the Washington-based Power Mobility Coalition.

The instruction to the DMERCs in a June 3 change request sets forth an algorithmic process for providing the appropriate MAE to correct mobility deficits.

"Utilizing such a process will ensure that the beneficiary (or caregiver) is able to maintain as much independence as physically and mentally possible, thereby ensuring the beneficiary's Mobility-Related Activities of Daily Living ... are maintained," CMS writes in a June 7 MedLearn Matters article (MM3791) on the instruction.

Suppliers May Have to Resubmit Certain Claims

The new policy is effective for mobility claims with dates of service from May 5 forward, but its implementation date is two months later. "We're giving them until July 5 to get their systems in place," a CMS spokesperson tells Eli.

Coping with rejection: If during that period you submit a claim that's rejected but that you believe fits under the new functional criteria, you should resubmit that claim after July 5, the spokesperson says.

Suppliers should contact their carriers before resubmitting claims so it doesn't look like double billing, CMS advises. They should also ask their carriers how they want those claims resubmitted.

The DMERCs will continue to use the existing certificates of medical necessity for manual wheelchairs, motorized wheelchairs and power-operated vehicles to facilitate claims adjudication. The next step for the DMERCs is translating the national policy to local coverage.

"We anticipate having a draft local coverage determination available later this month for a minimum 45-day comment period," says DMERC Region D Medical Director Dr. Robert Hoover. "If all goes as expected, we will have an LCD with an effective date that coincides with the new codes in January 2006."

Take action: In the meantime, the DMERCs strongly encourage suppliers to review the NCD with their referring physicians. 

Editor's Note: The MAE CR is at www.cms.hhs.gov/manuals/pm_trans/R37NCD.pdf. For more details on transitioning to the new NCD, visit www.adminastar.com/News/DMERCNews/DMERCNews.cfm.