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Eli's Rehab Report

Reader Question:

Medical Necessity for DME

Published on Thu Nov 01, 2001

Question: I am a physiatrist and I work closely with physical and occupational therapists. Often, I will suggest that a patient use a cane, wheelchair or other device, whereas the therapist sometimes disagrees. If I prescribe the equipment despite the therapist's objections, could I be at risk of the insurer saying that the item wasn't medically necessary? Since I prescribe the actual therapy, I always assumed that I made the final call on medical equipment, but this therapist suggests otherwise.
                                                  
California Subscriber                                                                              
   
Answer: As the treating physician, you are responsible for filling out the certificate of medical necessity (CMN), and you have to answer the questions on that form honestly and accurately. The payer can still deny the claim despite your prescription for and signature on the CMN if your answers do not correspond to the answers Medicare feels would support medical necessity for a particular device. For instance, the CMN for a manual wheelchair asks whether the patient requires a wheelchair to ambulate in his residence. If you answer "no" to this question, the patient is probably not going to receive the item.
 
The fact that the therapist disagrees with your opinion probably won't have a bearing on the coverage decision, unless the payer specifically asks for his or her opinion. Some DME suppliers will request a letter from the therapist to attach to the claim and CMN this most often occurs when the therapist sees the patient much more often than the physician, and may have a better idea of the patient's ambulation and other skills.
 
If the therapist sees your patients more often than you do, you may have to re-evaluate why you disagree so often on the medical necessity of these items. If your records are audited and it is revealed that the therapist disagreed with your prescription of DME most of the time, you may be "red flagged'' for an audit of your DME practices.
 
Keep in mind why you referred the patient to that therapist in the first place. Essentially, a referral to a particular therapist is the same as a referral to a specialist you need that person's expertise to treat the patient most effectively. Therefore disagreements on DME or other topics should probably warrant a more thorough conference than simply "vetoing'' the therapist's opinion.
 
Therapists, like any other practitioners, can file a complaint against you if they think  you are prescribing medically unnecessary items, and it's better to work closely with the therapist than to invite scrutiny. As the prescribing physician, you should be absolutely sure that the device is necessary before ordering it. Check with your state therapy association to confirm licensing laws.
   
Answers for You Be the Coder and Reader Questions provided by Laureen Jandroep, OTR, CPC, CCS-P CPC-H, owner of A+ Medical Management and Education, a national coding and reimbursement school and consulting firm in Absecon, N.J.; Judy Thomas, director of the reimbursement policy program for the American Occupational Therapy Association; and Bill Davies, owner of Medical Insurance Transmissions, a coding and billing firm in Alpharetta, Ga., that specializes in physical therapy claims.

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