Home Health & Hospice Week

Medical necessity concerns are a separate issue, CMS says.

If you're looking to the national coverage determination for power wheelchairs to shine some light on medical necessity requirements, get ready to remain in documentation darkness a little while longer.

During the Centers for Medicare & Medicaid Services' special Open Door Forum on the wheelchair NCD held Feb. 24, suppliers repeatedly raised concerns about documentation requirements - only to hear CMS officials insist that those concerns are a "side issue" that the NCD would not directly address.

Michael Johns, director of insurance for Electric Mobility Corp. of Sewell, NJ, was the first industry representative to raise the documentation issue during the sometimes contentious three-hour forum. He asked whether CMS would issue a new certificate of medical necessity for power mobility equipment. He also wondered whether the agency agrees that the CMN should be a standalone document definitively certifying the medical necessity of such equipment.

While CMS has been looking at the CMN for "quite a while," discussing what weight the agency might assign the document would be "inappropriate" at this time, said forum moderator Dr. Rich Lawlor. CMS is in the process of developing a regulation for power-operated vehicles "which most likely will carry the CMN as one of its items," Lawlor added.

The industry is eager to work with CMS to develop an expanded CMN that addresses elements in the new coverage proposal, noted Trienah Gorman of Mobility Products Unlimited in South Daytona, FL. The CMN must capture the data needed for payment, and providers place less importance on the document being one page long, she said.

Idea: CMS should consider equipment covered under the NCD on an item-by-item basis to determine what constitutes appropriate documentation, suggested Sharon Hildebrandt of the National Coalition for Assistive and Rehabilitation Technology. For example, capped rental equipment for short-term use should not require information beyond what's provided in theCMN, which CMS should revise to include questions pertaining to clinical criteria for coverage, she said.

Despite forum participants' repeated pleas for documentation clarification, CMS officials remained unmoved. CMS believes documentation is "not necessarily part" of the NCD, Lawlor said - though he did say he found hearing the industry's views on the matter to be "useful."

Suppliers Blast CMS Over In-Home Restriction

Many forum participants cheered CMS' proposal to eliminate the bed- or chair-confined criteria and move toward a functional-based paradigm. However, some questioned how CMS would apply the new standard. That's because the proposal says a beneficiary must be able to use a power wheelchair to improve her ability to perform a mobility-related activity of daily living such as toileting, feeding, dressing, grooming or bathing.

"We applaud CMS for proposing a new coverage standard based on a functional assessment of an individual's ability to complete their activities of daily living," said Seth Johnson of Pride Mobility Products in Exeter, PA. But he added, "We believe that mobility for mobility's sake should be clearly recognized as a qualifying need in the coverage policy."

In one of the more emotional threads of the discussion, some participants strongly criticized CMS over its decision to continue the "in the home" restriction for coverage of mobility equipment.

Charge: The restriction "leads to inappropriate equipment for a beneficiary's true environment, and it places the beneficiary at risk for morbidity and injury," cautioned Dr. David Wysocki, state director of therapeutic support services for Easter Seal UCP North Carolina and a member of the Clinician Task Force.

Response: CMS made its case that the in-home restriction resides in the law and to change the rule would require an act of Congress. However, several participants challenged that assertion, including Peter Thomas of the Washington-based ITEM Coalition and Kim Glaun with the Medicare Rights Center's Baltimore office.

"If you look at the language of the statute, you'll see that it does not actually require that medical necessity considerations be restricted only to the patient's needs within the four walls of the home," Glaun said.

Editor's Note: Comments submitted so far on the NCD are online at www.cms.hhs.gov/mcd/viewpubliccomments.asp?nca_id=143.