The Seven Elements

I have been meaning to write about this for some time. In fact, this was one of the reasons I wanted to create this blog.

I don’t think I’ve ever met any clinician who’s actually enjoyed fullfilling their documentation requirements for whatever medical matters pertain to their patients.  And for those of you reading this who are licensed practitioners, you know the future’s not so bright regarding this subject.  So who are we to blame for all this?  Our Federal and State government funding programs?  JCAHO?  Or do we blame the consumers who’ve been cheating the system for decades?  Form your own opinion.

Now let’s get down to business.  My workday consists of handling medical documents of all sorts.  A cornucopia of prescriptions, letters of medical necessity, physical/occupational evaluations, examination dictations, and so on.  The clients I mainly deal with are those who are permanently disabled, whether congenital or acquired, and are in need of some type of equipment to improve the quality of their lives.  Whatever the equipment, be it a posterior walker, manual wheelchair, or custom power wheelchair, my clients’ need for said equipment solely relies on what documentation I can gather to support their claims. 

I’m going to focus on one particular funding source, because it seems that so many others in the health insurance industry are following it’s wretched path, and that is Medicare.  Just the mere mention of this source stirs up endless negative thoughts.  Anyway, Medicare has kind of  ‘streamlined’  the process, especially for wheelchairs.  For the past 3 years, we’ve no longer had to send those dreaded CMN’s, or certificates of medical necessity, which were essentially an array of multiple guess questions and drop-down boxes that were often too vague to answer.  Some types of equipment like power wheelchairs, were once limited to specific diagnoses.  That limitation no longer exists and the CMN’s are no longer used, but today’s requirements actually make it more complicated to produce justification.  So much for streamlining.

Enter the Seven Elements.  These are the necessary components for a ‘powered mobility device’ (scooter or wheelchair) prescription to be valid and they are as follows:  

  1. Patient’s name.
  2. Pertinent diagnoses.
  3. Length of need (must be lifetime).
  4. Date of Face-to Face exam.
  5. Description of the item (can be general or specific).
  6. Physician’s signature (NO stamps! E-sign is acceptable).
  7. Date of physician’s signature (again, no stamps!).

Sounds simple enough, right?  Not so fast.  Everything that is documented on the prescription must be supported by the examination chart notes.  For example, the patient’s condition must severely limit their ability to perform any Mobility-Related Activities of Daily Living within their own home setting, either completely or in a timely manner.  Or, the patient’s limitation puts him/her at high risk of morbidity/mortality when attempting to perform these activities without the use of the prescribed device.  And you can’t just paraphrase this in the exam notes; the notes must specifically state how this limitation or condition prevents the completion of one or more MRADL’s.  Furthermore, the chart notes must explain how other less-costly alternatives (canes, walkers, manual wheelchairs) have been tried and/or considered and ruled out.  And last but not least, the patient’s home must be assessed for accessibility.  That’s right.  If the patient meets all the required medical criteria but their home cannot accomodate any type of mobility device, the claim is now unjust, unless provisions are made before the equipment is obtained.  Home modifications are very costly, even for the most simple cases, and are not covered by Medicare or most other insurance plans.  Now folks, this is just for your basic powered device, such as a motorized scooter, or a consumer power wheelchair (ones that have no custom components).  Custom manual and custom power wheelchairs require a physical or occupational therapist’s assessment in addition to the aforementioned documentation.  An equipment trial period may also be warranted.  The problem with this idiocy is that most providers don’t stock this kind of equipment for a ‘test drive’.  Hence the word custom.  Are you listening, Medicare?  Now I can’t stay up all night and list every stinking detail, which is why I provided the link above.  Scroll through it and you’ll find all the information you need when ordering this type of equipment, if you can spare a couple of hours.  A tip for all  physician’s out there:  if ANY of the seven elements are missing from your Rx, your patient’s claim will be denied as not medically necessary.  I’ve seen it happen.  Finally, all the documentation that is produced after the face-to-face exam must be fowarded to the medical equipment supplier no later than 45 days after the exam, or it’s back to the drawing board you go.  One good thing (well, not that good) is that this ‘exam’ must be billed with an add-on CPT code, G0372, in addition to the office visit charges.  The last time I checked the Medicare fee schedule for this add-on, it was a little over $20.  I’m SURE that’ll make up for all the documentation efforts.

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