esMDeDoC – Automating PMD Coverage

October 23th, 2013

• Over View of the PMD Benefit Coverage

• Over View of e-Clinical Template

• ICD-10 Codes supporting eDoC

Agenda

• 2005 - National Coverage Determination (NCD) process

• CMS function-based criteria for Mobility Assist Equipment (MAE)– Algorithmic process - Clinical Criteria for MAE Coverage– Replaced prior requirement - “bed- or chair-confined”

• MMA – expanded types of health professionals ordering PMDs

Power Mobility Device (PMD)

• For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. For the items addressed in this local coverage determination, the criteria for "reasonable and necessary", based on Social Security Act §1862(a)(1)(A) provisions, are defined by the following indications and limitations of coverage and/or medical necessity.

PMD Benefit

• Personal mobility deficit– Impairment in performing Mobility Related Activities of Daily

Living (MRADLs)• Toileting, feeding, dressing, grooming, and bathing • In customary areas in the home

• Determining appropriate MAE - PMD addressing mobility deficit– Physicians / treating practitioners - Clinical Criteria for MAE

Coverage

PMD Benefit

• Does the beneficiary have a mobility limitation that significantly impairs his/her ability to participate in one or more MRADLs in the home?

• Are there other conditions that limit the beneficiary’s ability to participate in MRADLs at home?

• • If these other limitations exist, can they be ameliorated or

compensated sufficiently such that the additional provision of MAE will be reasonably expected to significantly improve the beneficiary’s ability to perform or obtain assistance to participate in MRADLs in the home?

Clinical Criteria

• Does the beneficiary or caregiver demonstrate the capability and the willingness to consistently operate the MAE safely?

• Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?

• Does the beneficiary’s typical environment support the use of wheelchairs including scooters/POVs?

Clinical Criteria

• Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home to participate in MRADLs during a typical day?

• Does the beneficiary have sufficient strength and postural stability to operate a POV/scooter?

• Are the additional features provided by a power wheelchair needed to allow the beneficiary to participate in one or more MRADLs?

Clinical Criteria

Clinical Criteria

• Face to Face (F2F) Examination– Suggested Electronic Clinical Template Elements of a

Progress Note Documenting a Face-to-Face PMD Examination

DRAFT v9.8 (11/02/12)

https://www.cms.gov/Research-Statistics-Data-and-Systems/Computer-Data-and-Systems/ESMD/ElectronicClinicalTemplate.html

Physician Requirements

Components of PMD Clinical Template

• Chief Complaint• History of Present Illness• Past Medical History• Review of Systems• Physical Exam• Patient Assessment and Plan• Physician Information and 7 Element Order

Components focused on data to support a PMD order and coverage

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• 7- Element Order– Beneficiary’s name– Description of the item that is ordered

• This may be general – e.g., “power operated vehicle”, “power wheelchair”, or “power mobility device”– or may be more specific.

– Date of the face-to-face examination– Pertinent diagnoses/conditions that relate to the need

for the POV or power wheelchair– Length of need– Physician’s signature– Date of physician signature

Physician Requirements

Codification of Diagnosis/Condition – (Functionality)

• ICD Codes– ICD-9 – in final year of utilization– ICD-10 – Transitioning to Implementation 10/01/2014

• International Classification of Functionality

• SNOMED

Pertinent Diagnoses/Conditions

Paraplegia (paraparesis) and quadriplegia (quadriparesis) G82-

• G82 - Paraplegia (paraparesis) and quadriplegia (quadriparesis)– G82.2 - Paraplegia

• G82.20 …… unspecified• G82.21 …… complete• G82.22 …… incomplete

– G82.5 Quadriplegia• G82.50 …… unspecified• G82.51 …… C1-C4 complete• G82.52 …… C1-C4 incomplete• G82.53 …… C5-C7 complete• G82.54 …… C5-C7 incomplete

 

Diagnosis – Automated Coverage

G82.5 Quadriplegia

G82.5 QuadriplegiaCervical Radiculopathy Patterns Root Symptoms Motor Function Reflex C2 Posterior occipital headaches,

temporal pain None None

C3 Occipital headache, retro-orbital or retroauricular pain

None None

C4 Base of neck, trapezial pain None None C5 Laeral arm pain Deltoid Biceps C6 Radial forearm pain, pain in

thumb and index fingers Biceps, wrist extension

Brachioradialis

C7 Middle finger pain Triceps, wrist flexion

Triceps

C8 Pain in ring and little fingers Finger flexors None T1 Ulnar forearm pain Hand intrinsics None

International Classification of Functioning, Disability and Health (ICF)

• b - BODY FUNCTIONS• s - BODY STRUCTURES• d - ACTIVITIES AND PARTICIPATION• e - ENVIRONMENTAL FACTORS

http://www.who.int/classifications/icf/en/

ICF - Domains

• b1 - CHAPTER 1 MENTAL FUNCTIONS• b2 - CHAPTER 2 SENSORY FUNCTIONS AND PAIN• b3 - CHAPTER 3 VOICE AND SPEECH FUNCTIONS• b4 - CHAPTER 4 FUNCTIONS OF THE CARDIOVASCULAR,

HAEMATOLOGICAL, IMMUNOLOGICAL AND RESPIRATORY SYSTEMS• b5 - CHAPTER 5 FUNCTIONS OF THE DIGESTIVE, METABOLIC AND

ENDOCRINE SYSTEMS• b6 - CHAPTER 6 GENITOURINARY AND REPRODUCTIVE FUNCTIONS• b7 - CHAPTER 7 NEUROMUSCULOSKELETAL AND MOVEMENT-

RELATED FUNCTIONS• b8 - CHAPTER 8 FUNCTIONS OF THE SKIN AND RELATED

STRUCTURES

ICF - BODY FUNCTIONS

b7 - CHAPTER 7 NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS

• b710-b729 Functions of the joints and bones (b710-b729)• b730-b749 Muscle functions (b730-b749)• b750-b789 Movement functions (b750-b789)• b798 Neuromusculoskeletal and movement-related functions, other

specified• b799 Neuromusculoskeletal and movement-related functions,

unspecified

ICF - BODY FUNCTIONS

b7 - CHAPTER 7 NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONSb750-b789 Movement functions (b750-b789)• b750 Motor reflex functions

– b7500 Stretch motor reflex– b7501 Reflexes generated by noxious stimuli – b7502 Reflexes generated by other exteroceptive stimuli – b7508 Motor reflex functions, other specified– b7509 Motor reflex functions, unspecified– b755 Involuntary movement reaction functions

• b760 Control of voluntary movement functions– b7600 Control of simple voluntary movements – b7601 Control of complex voluntary movements

– b7602 Coordination of voluntary movements – b7603 Supportive functions of arm or leg – b7608 Control of voluntary movement functions, other specified – b7609 Control of voluntary movement functions, unspecified – b765 Involuntary movement functions– b7650 Involuntary contractions of muscles – b7651 Tremor – b7652 Tics and mannerisms – b7653 Stereotypies and motor perseveration – b7658 Involuntary movement functions, other specified– b7659 Involuntary movement functions, unspecified

• b770 Gait pattern functions• b780 Sensations related to muscles and movement functions• b789 Movement functions, other specified and unspecified

ICF - BODY FUNCTIONS

b7 - CHAPTER 7 NEUROMUSCULOSKELETAL AND MOVEMENT-RELATED FUNCTIONS

b750-b789 Movement functions (b750-b789)• b760 Control of voluntary movement functions

– b7602 Coordination of voluntary movements • Functions associated with coordination of simple and complex voluntary

movements, performing movements in an orderly combination. – Inclusions: right left coordination, coordination of visually directed movements,

such as eye hand coordination and eye foot coordination; impairments such as dysdiadochokinesia

ICF - BODY FUNCTIONS

References/Contact Information

LinksesMD Initiative: http://wiki.siframework.org/esMD+Initiative esMD Program: http://www.cms.gov/esmd

Contact InformationRobert Dieterle – esMD Initiative Coordinator (rdieterle@enablecare.us)Sweta Ladwa – ESAC (sweta.ladwa@esacinc.com )Dan Kalwa – CMS (Daniel.Kalwa@cms.hhs.gov) Mark Pilley – Co Lead (m.pilley@strategichs.com)Dr. Viet Nguyen – Co Lead (viet.nguyen@systemsmadesimple.com )

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