Clinical and documentation demands for mobility-related activities of daily living.
- By Julie Piriano
- Sep 01, 2010
In the DME industry the age-old confl ict between operations and sales is magnified by high audit activity, third-party payor scrutiny of claims, and the overarching caveat that “prior authorization is not a guarantee of payment.” A key way increase your chances of reimbursement after the sale is a solid understanding of the first requirement outlined in the Medicare National Coverage Determination (NCD) forMobility Assistive Equipment (MAE) as many payors use this benchmark:
Does the beneficiary have a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home?
The Medicare Local Coverage Determination (LCD) describes Mobility-Related Activities of Daily Living (MRADLs) as toileting, feeding, dressing, grooming, and bathing in the customary locations of the home. The requirement seems like a simple question that, when answered “yes,” would let a clinician or physicianrecommend or prescribe an appropriate mobility device.
Unfortunately, it is not simple. It would be much simpler if the question itself provided a direct connection between the “issue” and the “intervention” based on evidence like a CT scan or X-ray. For example, “Does the beneficiary have a broken leg that will require a cast and physical therapy?” But with the provision of MAE, answering “yes, the beneficiary has a mobility limitation” is just the starting point for investigating the limitation and how it is best treated.
The NCD has defined a mobility limitation as one that:
- Prevents the beneficiary from accomplishing the Mobility Related Activities of Daily Living (MRADL) entirely; or
- Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in MRADLs; or
- Prevents the patient from completing MRADLs in a reasonable time frame.
This raises some new questions: How does a clinician or physician evaluate it and satisfactorily document that the prescription of mobility assistive equipment is the best course of medical care? How does the DME provider determine whether medical necessity has been established prior to delivering, billing and collecting for MAE?
From a functional and clinical perspective the beneficiary would traditionally be evaluated on their ability to perform the steps necessary to carry out these activities of daily living (ADLs). While this is important in the overall assessment, it is irrelevant if they cannot get to the customary location of the home independently, safely and in a timely manner. The movement from point A to point B to perform or participate in the activity is the critical piece of evidence that must be evaluated to demonstrate a mobility limitation.
When a mobility limitation is present, it is important for the provider to know what interventions have been tried and failed and what has been considered and ruled out as MAE is typically the last recommendation to treat a mobility limitation. For example, if the primary reason for the mobility limitation is secondary to cardio-respiratory disease you will want to review past medical records to know if medical or pharmaceutical intervention, such as increasing the oxygen liters per minute or adding or changing prescription medication, has mitigated the symptoms that typically cause the mobility limitation. Educating physicians to ask their patient about getting to the bathroom, bedroom and kitchen and documenting any challenges is important to ensure this information is in writing. If the physician determines that further medical intervention will no longer alleviate the symptoms impairing mobility and that the prescription of MAE would, it must be discernible from a review of the written medical records.
Similarly, if the mobility limitation is due to a condition that could be resolved by surgical intervention, then this is typically the course of care considered or carried out. When the physician documents that the individual is not a surgical candidate or surgery is not expected to, or did not treat the mobility limitation this information should be evident from the face-to-face examination and past medical record.
Lastly, the mobility limitation may be resolved by therapeutic intervention, such as physical and occupational therapy, to address the functional aspect of the mobility limitation(s) outlined in the NCD:
Challenges that “prevent the beneficiary from accomplishing the MRADLs entirely” might include distance, terrain and the individual’s ability to negotiate obstacles in the home. A documentation review should verify that the patient is unsafe, not independent or unable to overcome these challenges in a timely manner to confirm a mobility limitation that warrants an MAE.
Compromised balance, weakness, limitations in range of motion, abnormal muscle tone/reflexes, absent or impaired sensation may “place the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to participate in MRADLs” when moving from point A to point B. Therapeutic intervention to achieve safe, independent mobility could include MAE, such as an ambulation aid or manual wheelchair. If this resolves the mobility limitation the recommendation and prescription of a powered mobility device (PMD) would not be warranted. If the medical record indicates the individual is not safe or requires any level of assistance from another person to ambulate or self-propel then the patient is not independent in the use of “lower level” equipment and the provider has a higher level of assurance that the coverage criteria for a PMD has been met.
The presence of pain, in-coordination or limited endurance might “prevent the beneficiary from completing the MRADLs within a reasonable time frame.” Educate clinicians to ask patients about their typical “mobility day.” Beneficiaries that plan their day around toileting or forgo nutrition and hydration, dressing or daily grooming and hygiene because it takes too much out of them might do so because of the time required, not because they have trouble accomplishing those activities. Therapy services to increase the beneficiary’s speed, endurance, efficiency and timeliness for safe, independent mobility will be documented by the clinician. A review of the medical record should indicate the goal can only be met with the provision of MAE and the clinical considerations for the equipment that will allow the beneficiary to participate in their MRADLs in a timely manner should be evident to the provider.
The evidence of a mobility limitation is not as easy as a lab test, but it can be quantified. To determine the risk associated with an audit or claim review it is imperative to put a process in place to review the beneficiary’s medical record before the sale. If step one has not been met and a mobility limitation has not been established, the risk for monetary recoupment is increased as the need for mobility assistive equipment would not be established.
This article originally appeared in the September 2010 issue of HME Business.
Julie Piriano, PT, ATP/SMS, is VP, Clinical Education, Rehab Industry Affairs & Compliance Officer for Pride Mobility Products.