AOPA Update: Additional Information on CMNs & Medicare Audits

AOPA Update: Additional Information on CMNs & Medicare Audits

Kathy Dodson

6/3/2005

AOPA would like to provide some additional information regarding a June
2004 federal court decision in California that dealt with what
information a DMERC may request to determine if services are medically
necessary. The findings, in brief, were that the DMERC could not
request additional information over and above the Certificate of Medical
Necessity (CMN), which suppliers were required to submit for motorized
wheelchairs. Several recent comments on the list serve encouraged O&P
professionals to consider using this decision as the basis for refusing
to supply to the DMERCs additional medical information over and above
the prescription.

 

After reviewing the findings of this case last year, AOPA determined it
is not directly applicable to Medicare services not requiring the
submission of a CMN. In the Centers for Medicare and Medicaid Services
(CMS) terminology, a CMN refers to a very specific form, mandated by
Congress and developed by CMS, which must be completed by the supplier
and physician in order to make a service eligible for payment. (It does
not refer to the general medical necessity information contained in O&P
patient notes or to individual letters of medical necessity written by
O&P facilities or referring physicians.) The DMERCs use the contents of
the official CMN form to determine if services are medically necessary.

 

While O&P services are certainly subject to the requirement that they be
medically necessary in order to be covered, CMS does not require that
O&P facilities obtain CMNs. AOPA believes, therefore, that there is no
basis to argue that the CMN is sufficient documentation. And while a
CMN, if it is detailed enough, may serve as a prescription according to
Medicare's Program Integrity Manual, CMS does not state that a
prescription can function as a CMN. In theory, for a prescription to
serve as a CMN it need to have all of the information contained in a CMN
and be subject to the same restrictions as CMNs.

 

For example, the prescription would have to contain patient identifying
information, a list of the various criteria that have to be met before a
device would be covered (for example, all of the coverage criteria for
an AFO for an ambulatory patient), a detailed list of all of the devices
and components used in the device, the facility charge for each and the
Medicare fee schedule allowable for each.

 

In addition, unlike current prescriptions which can be completed by the
O&P facility and sent to the physician for signature, portions of a
prescription that serve as a CMN can only be completed by the physician.
For example, in current CMNs, only the physician is legally allowed to
respond to all of the questions dealing with whether or not the patient
meets all of the medical policy requirements for coverage. Suppliers
are prohibited from completing this section and violations of this
prohibition can result in fines and other penalties.

 

AOPA understands the field's frustrations in having to deal with DMERC
requests for additional documentation and we are working toward a
solution on your behalf. We do not recommend that you count on this
California case to exempt you from providing information to your DMERCs.