(July 16, 2011): As Zone Program Integrity Contractor (ZPIC) audits of Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) companies continue to climb, the Department of Health and Human Services, Office of Inspector General (HHS-OIG), has now reported that more than one-half of the recent power wheelchair claims by Durable Medical Equipment (DME) suppliers were improper during the period audited. Notably, this will likely reinforce the likelihood and frequency that ZPICs across the country will continue to focus a considerable portion of their resources on DME companies, especially those whose sell power wheelchairs.
I. ZPIC Audits Are Likely to Continue Climbing in Light of the OIG's Report:
As the OIG’s July 2011 report details, approximately 61% of the power wheelchair claims billed to Medicare during the period reviewed were either medically unnecessary or lacked sufficient documentation for the OIG to determine medical necessity. Collectively, these improper billings accounted for $95 million of the $189 million paid by Medicare for power wheelchairs.
II. Types of Problems Noted with Power Wheelchair Claims:
In reviewing these Medicare power wheelchair claims, the OIG conducted a random sample of 375 claims. The OIG’s review included both standard and complex wheelchairs. Based on records submitted by DME suppliers, the OIG found that:
- 9% of all power wheelchairs were medically unnecessary
- 52% had claims with insufficient documentation to determine medical necessity.
A number of specific problems are outlined in the OIG’s July 2001 report. Two of the most significant concerns included:
- Some Medicare patients received power wheelchairs when only a manual wheelchair, cane, or walker was needed.
- Many of the claims were for power wheelchairs appeared to be justified and medically necessary based on suppliers' records. However, when the OIG examined the corresponding ordering physicians’ records, most of these same power wheelchairs were found to be either:
- Medically unnecessary, or
- Insufficiently documented, or
Essentially, the suppliers’ records were either unsupported, or, in some cases, were contradicted by the related ordering physicians’ medical documentation.
III. Summary of the OIG’s Findings:
The OIG’s July 2011 report is especially significant in light of the fact that the agency previously issued two prior reports based on the same sample of power wheelchairs. While the earlier reports noted that there significant coding and documentation requirements, this recent report focuses on supplier compliance deficiencies. Summarizing its findings among the three reports, the OIG noted that 80% of the power wheelchair claims sampled did not meet Medicare’s documentation and / or coverage requirements. The OIG concluded its report by saying:
"Although CMS has taken steps since 2007 to decrease errors among suppliers of power wheelchairs and other DME, Medicare has paid significantly more in recent years for power wheelchairs than it did in 2007. These increases may indicate that CMS continues to pay for power wheelchairs that are not medically necessary and/or have claims that do not meet documentation requirements."
IV. Practical Impact of the OIG’s Findings:
As a participating provider, power wheelchair suppliers have an obligation to ensure that their claims fully comply with Medicare’s coverage and billing requirements. Unfortunately, as the OIG’s report reflects, most of the power wheelchair claims paid by Medicare have not met these requirements.
From a practical standpoint, the OIG’s findings are not new – both physicians prescribing power wheelchairs and the suppliers of this equipment have repeatedly failed to either meet Medicare’s documentation requirements or show that this equipment is medical necessity for the care of the patient and that less expensive assistive devices (such as a cane, walker or manual wheelchair) are insufficient to meet the patients’ medical needs. As a result, these claims have been regularly examined by various government law enforcement agencies (e.g. OIG, the Federal Bureau of Investigation and the U.S. Department of Justice) and CMS’ contractors (e.g. ZPICs), and DME Medicare Administrative Contractors (DME MACs)). With the release of this report, suppliers will likely find their practices under extended scrutiny.
Both physicians who prescribe power wheelchairs and DMEPOS suppliers who fill these prescriptions must ensure that their practices fully comply with applicable statutory and regulatory requirements. As discussed below, the completion of a"gap analysis" is an essential element of an effective Compliance Plan.
V. Conducting a Gap Analysis of Your Power Wheelchair Claims Documentation Before an Audit is Conducted:
From a compliance standpoint, unless they have recently done so, all power wheelchair suppliers should immediately conduct a gap analysis to determine whether their practices fully comply with applicable statutory and regulatory requirements. Gap analyses are routinely used in practically every industry to assist Compliance Officers and others in identifying corrective actions that need to be taken in order to bring an entity’s practices to an acceptable baseline of compliant operations. Gap analyses conducted by health care providers must analyze two aspects of their practices in order to ensure compliance. These include:
Requirement #1: A review of their documentation, coding and billing practices. Additionally, the evidence must reflect that the power wheelchair billed was medically necessary and appropriate.
Requirement #2: A review of the supplier’s business practices to ensure that the supplier is not committing violations of the Federal Anti-Kickback, Stark or other statutory enforcement requirements.
This article focuses on the first set of requirements set out above. Every gap analysis begins with a review of applicable statutory and regulatory provisions. Additionally, suppliers must assess Medicare’s latest guidance covering documentation, coding and billing requirements. In addition to issuances by CMS, Local Coverage Determinations (LCD’s), Local Medical Review Policies (LMRP’s) must be reviewed so that specific regional directives are also identified.
Upon completing an analysis of the regulatory landscape, suppliers must next conduct a baseline assessment of its existing documentation, coding and billing practices. At this point in the process, a supplier can compare its practices with the government’s requirements. This process is often referred to as a gap analysis. In this fashion, a supplier is able to use this performance measurement tool to determine the extent to which action must be taken to bring the supplier’s practices up to the desired level of compliance.
VI. CMS’s Power Wheelchair Documentation Requirements:
As an initial starting point, power wheelchair suppliers should examine the "Face-to-Face Examination Checklist" that has been issued by CMS in MLM Matters Number SE1112. As the guidance reflects, Power Wheelchairs are one of several devices collectively classified as "Power Mobility Devices" which qualify for coverage under Medicare Part B.
CMS has defined "Power Mobility Devices" as covered items of DME which include a Power Wheelchair or a Power Operated Vehicle (POV) that a beneficiary uses in the home. Effective May 5, 2005, CMS revised its national coverage policy to create a new class of DME. This new class of equipment was identified as "Mobility Assistive Equipment" (MAE), which included a continuum of technology-- from canes to power wheelchairs.
A. Ordering / Treating Physician Requirements.
Regardless of how they are described, prescribing or ordering physicians are the proverbial "front-line" in the claims process. These physicians are responsible for determining whether a PMD is medically necessary and appropriate. If so, the physician must:
Provide the power wheelchair supplier with supporting documentation consisting of portions of the medical record essential for supporting the medical necessity for the PMD in the beneficiary’s home. In order to document the need for a PMD there are a few specific statutory requirements that must be met before the ordering physician can issue a written prescription for the equipment:
- " An in-person visit between the ordering physician and the beneficiary must occur. This visit must document the decision to prescribe a PMD.
- A medical evaluation must be performed by the ordering physician. The evaluation must clearly document the patient’s functional status with attention to conditions affecting the beneficiary’s mobility and their ability to perform activities of daily living within the home. This may be done all or in part by the ordering physician. If all or some of the medical examination is completed by another medical professional, the ordering physician must sign off on the report and incorporate it into their records.
- Items 1 and 2 together are referred to as the face-to-face exam. Only after the face-to-face examination is completed may the prescribing physician write the prescription for a PMD. This prescription has seven required elements and is referred to as the seven-element order which must be entered on the prescription only by the physician.
- The records of the face-to-face examination and the seven-element order must be forwarded to the PMD supplier within 45 days of the completion of the face-to-face examination.
- CMS’ National Coverage Determination requires consideration as to what other items of mobility assistive equipment (MAE), e.g., canes, walkers, manual wheelchair, etc., might be used to resolve the beneficiaries mobility deficits. Information addressing MAE alternatives must be included in the face-to-face medical evaluation." (MLM SE 1112, page 2 of 7).
Once the above requirements have been met, an ordering physician can properly issue a prescription for a PMD.
B. Ordering / Treating Physician Requirements.
As MLM SE 1112 reflects, the following checklist is not to be used as a substitute for a patient’s underlying medical records. Having said that, the checklist serves as a helpful tool for verifying that an ordering physician’s documentation (as reflected by the patient’s medical records) are both complete and sufficient to meet Medicare’s coverage requirements. The following information should be fully documented in the patient medical records:
Documentation of "History" Component
The medical record for the patient includes the following history:
_____ Signs/Symptoms that limit ambulation;
_____ Diagnoses that are responsible for these signs/symptoms;
_____ Medications or other treatment for these signs/symptoms;
_____ Progression of ambulation difficulty over time;
_____ Other diagnoses that may relate to ambulatory problems;
_____ How far the patient can ambulate without stopping and with what assistive device, such as a cane or walker;
_____ Pace of ambulation;
_____ History of falls, including frequency, circumstances leading to falls, what ambulatory assistance (cane, walker, wheelchair) is currently used and why it is not sufficient;
_____ What has changed in the patient’s condition that now requires the use of a power mobility device;
_____ Reason for inability to use a manual wheelchair; such as assessment of upper body strength;
_____ Why does the patient need a power wheelchair rather than each level of mobility assistive equipment (a cane, walker, optimally configured manual wheelchair, scooter)?
_____ What are the reasons that the patient should not or could not use a cane, walker, optimally configured manual wheelchair or power operated vehicle (scooter) in the home to satisfy their needs? and
_____ Description of the home setting, including the ability to perform activities of daily living in the home, as well as the ability to utilize the PMD in the home.
Documentation of Examination Component
The physical examination is relevant to the patient’s mobility needs and the medical record for the patient contains:
_____ Weight and Height
_____ Musculoskeletal examination
• Arm and leg strength and range of motion;
_____ Neurological examination
• Balance and coordination
• If the patient is capable of walking, the report should include a documented observation of ambulation (with use of cane or walker as appropriate).
DMEPOS suppliers have an obligation to ensure that power wheelchairs billed to Medicare fully meet the program’s documentation, coding and billing requirements. To that end, it important that suppliers carefully examine both their relationships with prescribing suppliers and the documentation of medical necessity associated with any claims billed to Medicare. Importantly, it isn’t merely a paper-only exercise which requires that you "document" medical necessity – a patient must actually require this type of assistive device. Therefore, the documentation must accurately reflect a patient’s diagnosis, signs / symptoms and clinical limitations which limit ambulation and necessitate the use of a power wheelchair.
At the end of the day, both the physician who "certifies" that a power wheelchair is medically necessary and the DME supplier who "fills" the prescription for the chair can be help liable for submitting an invoice for a wheelchair that is not medically necessity. If your DME company is subjected to a ZPIC audit of the power wheelchairs and other devices / supplies it has billed to Medicare, it is ESSENTIAL that you are able to show that the device at issue was, in fact, medically necessary. Waiting until you have been audited by a ZPIC to request supporting documentation from an ordering physician is too late. By that time, a physician may have closed his practice, passed away, or lost the documentation you need. DME suppliers should approach documentation like we were taught as young adults to approach driving: "Drive Defensively." Assume you will eventually be audited -- make sure your documentation is accurate and complete. How should you respond if a physician cannot provide sufficient documentation? Don't fill the prescription!
Robert W. Liles, Esq., serves as Managing Partner at Liles Parker. Robert and other attorneys at our health law firm have extensive experience representing health care providers in ZPIC audits of post-payment claims and in assisting providers get off of prepayment review. Additionally, we can assist with the development and implementation of an effective Compliance Program. Should you have questions, please call Robert for a complimentary initial consultation. He can be reached at 1 (800) 475-1906.