CERTIFICATE OF MEDICAL NECESSITY NO LONGER REQUIRED
The Centers for Medicare & Medicaid Services (CMS) today took another step to streamline and ensure appropriate access for people with Medicare to power operated vehicles – commonly called “scooters” â and power wheelchairs. In an interim final rule with opportunity to comment that went on display today at the Federal Register, CMS clarified the requirements for prescribing, supplying, and receiving payment for these vehicles. The interim final rule builds on current clinical standards of care.
“This interim final rule is a critical step in ensuring that people with Medicare have access to appropriate technology to assist them with mobility,” said CMS Administrator Mark B. McClellan, M.D., Ph.D. “Along with Medicare’s decision earlier this year to replace the old ‘bed or chair confined’ standard with new functional criteria for eligibility, this interim final rule is part of a comprehensive strategy to help Medicare beneficiaries get the mobility assistance equipment they need while avoiding unnecessary administrative burdens and inappropriate Medicare spending. An appropriate professional evaluation and its documentation in the patient’s record are the key to the effective use of mobility devices and the quality and continuity of care for our beneficiaries.”
CMS is eliminating the requirement that a Certificate of Medical Necessity (CMN) signed by the prescribing physician or other treating practitioner accompany claims for power wheelchairs and scooters. In place of the CMN, the interim final rule describes the clinical documentation from a patient’s medical record that must be submitted along with a written prescription to the supplier before the supplier delivers a power wheelchair or scooter to the beneficiary.
“Documentation in the medical record of the beneficiary’s need for assistance with mobility in the home, as well as the type of technology needed, not only is the best evidence of medical necessity – it also helps to promote continuity of care for our beneficiaries,” said CMS Acting Chief Medical Officer, Barry Straube, M.D. “And we are recognizing this in our payments to providers.”
Medicare already pays under the Physician Fee Schedule for the office visit required to evaluate the beneficiary. Because of the changes in the documentation suppliers will need before delivering a power wheelchair or scooter, CMS is authorizing an additional payment to physicians and treating practitioners for preparing and providing the required documentation to the equipment supplier. To receive this payment, the physician or treating practitioner will include a special billing code on the claim for the office visit.
CMS is today notifying physicians and other treating professionals, as well as PMD suppliers, of this interim final rule through its Medicare listserves. In addition, between the issuance of this interim final rule and its effective date in 60 days, CMS will target educational efforts to physicians and other practitioners who prescribe power wheelchairs and power scooters as well as to suppliers of PMD, to help them understand the new criteria and new documentation requirements. CMS will also provide billing instructions for suppliers before the implementation date.
To help suppliers evaluate and document the patient’s need for a particular type of technology, the contractors who process durable medical equipment claims will issue specific guidance about what information from the beneficiary's medical record is needed to demonstrate the medical necessity of the equipment. This guidance will underscore that an appropriate coverage determination for these products will take into account the patient’s medical history, elements of a physical assessment such as strength and range of motion, a functional needs assessment as documented in the medical record, as well as the availability of other types of devices.
In early September, CMS will hold a special Open Door Forum to address power wheelchair and power scooter issues. Open Door Forums offer physicians, suppliers and other stakeholders the opportunity to participate in person or by conference call in a discussion with senior staff about Medicare policies.
The interim final rule issued today is the latest action CMS is taking to implement a Power Wheelchair Initiative first announced in April 2004. That multi-pronged initiative is focused on improving coverage, payment policies, and quality of suppliers of power wheelchairs and power scooters. In addition to developing new, functional criteria for coverage, CMS is adopting new billing codes for power wheelchairs and power scooters that will allow Medicare to differentiate among types of equipment with different features and pay more accurately depending on the characteristics of the particular chair.
The interim final rule also implements provisions in the Medicare Modernization Act of 2003 (MMA) affecting power wheelchairs and power scooters, including a provision requiring a physician or treating practitioner (who can be a physician assistant, nurse practitioner, or clinical nurse specialist) to conduct a face-to-face examination of the beneficiary before prescribing a power wheelchair or power scooter.
The interim final rule also eliminates a restriction that allows only a specialist in physical medicine, orthopedic surgery, neurology or rheumatology to prescribe a power scooter. This restriction, which no longer reflects current standards of care, has created barriers to appropriate prescribing of equipment to meet a patient’s needs. The new rule allows both physicians and treating practitioners to prescribe a power wheelchair or power scooter. Finally, the interim final rule requires a supplier, before billing Medicare, to obtain a written prescription, signed and dated by the physician or treating practitioner who performed the face-to-face examination, within 30 days of the examination.
The actions CMS is taking today underscore the principle that the beneficiary’s physician or treating practitioner is in the best position to evaluate and document the beneficiary’s clinical condition and medical needs. Good medical practice requires that this evaluation be adequately documented. Thus, to minimize the documentation requirements for providers while assuring that documentation is adequate, physicians and treating practitioners will now submit copies of relevant existing documentation from the beneficiary’s medical record, rather than having to transcribe medical record information onto a separate form such as a CMN.
The interim final rule will be published in the August 26 Federal Register, and will become effective for services on or after October 25. Comments will be accepted until November 25, and a final rule will be published at a later date.
Note: The Interim Final Rule and a Fact Sheet will be posted on the CMS Website at: