RE I MB U R SE ME NT & C LINICA L ISSUES
WHAT DOES A SUPPLIER NEED TO KNOW? Written by: ED BONK, PT, ATP/SMS, CRTS®
When I was first asked by Amy Odom to write this article about Complex Rehab Technology (CRT) documentation: “What does a supplier need to know?” I thought, “What don’t they need to know?” In other words, they need to know everything! I separated the topics I will review into the following sections: 1. Coverage criteria 2. Documentation requirements a. Basic clinical findings b. Critical clinical findings 3. The Therapist’s perspective 4. Supplier’s perspective – What can we do? 5. Putting it all together
COVERAGE CRITERIA It is essential ATPs/RTSs have a working knowledge of the coverage criteria for all the CRT items/equipment by all payers that they are credentialled. If they are not knowledgeable, how can they educate therapists they work with, who may not truly understand what needs to be documented? I like to start with Medicare. They set the standard almost all other payers follow. The first part of the coverage criteria is understanding the Medicare algorithm for mobility assistive devices. It is a good roadmap for therapists to use when writing their assessment to medically rule out less costly, less medically assistive devices. Most other payers use this algorithmic approach to identify the most medically appropriate device.
impairs his/her ability to participate in one or more MRADLs such as toileting, feeding, dressing, grooming and bathing in customary locations in the home. A mobility limitation is one: • Prevents the beneficiary from accomplishing an MRADL entirely. • Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL. • Prevents the beneficiary from completing an MRADL within a reasonable time frame. Many state Medicaids follow this approach but also have other/additional coverage criteria. The ATP/RTS must have a good working knowledge of their state Medicaid’s regulations.
DOCUMENTATION REQUIREMENTS The patient’s clinical presentation should be clearly documented. I like to categorize clinical information into one of two groups: BASIC CLINICAL FINDINGS Examples of the basic clinical information would be diagnoses, range of motion, strength, posture, sitting and standing balance, transfers, pain level, ambulation and tone. CRITICAL CLINICAL FINDINGS
The algorithm is a hierarch of assistive devices. Starting with a cane, which is the least costly and least medically assistive, and working upward to the most costly and most medically related, a Group 3 power wheelchair. The second part of the Medicare coverage criteria is understanding limitations of mobility assistive activities of daily living (MRADLs). The beneficiary must have a mobility limitation that significantly
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DIRECTIONS 2022.3
Examples of critical clinical information should be related to how they impact the patient’s mobility. These include: their current equipment, upper extremity range of motion and strength, tonal influences if abnormal, skin integrity andcardiorespiratory status. • Current equipment – what are they using now and why is it no longer medically appropriate? • Manual Muscle Testing (MMT) grades should be used, but they should also be clarified. If a patient presents with 4/5 UE MMT throughout, this translates to ‘good’ UE strength. A reviewer at an insurance company might ask, “If they have good upper extremity strength, then why can’t they propel a manual wheelchair?” • Skin integrity: both the client's history and current skin compromise.
