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Issue 2006-04, April 2006
MLN Matters. . .Information for Medicare Providers
(Issued by the Centers for Medicare & Medicaid Services)
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Payment for Power Mobility Device (PMD) Claims
Note: This article was revised on March 24, 2006, to emphasize that providers submitting claims on or after April 1, 2006 must bill the E/M and the G0372 code on the same claim. |
Provider Types Affected
Physicians, providers, and non-physician practitioners billing Medicare carriers, durable medical equipment regional carriers (DMERC), regional home health intermediaries (RHHI), and/or fiscal intermediaries (FIs) for PMDs and services related to prescribing PMDs
Important Points to Remember
Options for Submitting G0372* and Evaluation and Management (E/M) Codes
Providers billing a Medicare carrier have the following options for submitting the G0372 code and the E/M code during January 1, 2006, through March 31, 2006:
- Submit the G0372 code and E/M now on the same claim. Payment for these claims will be held through March 31, 2006.
- Hold all claims containing the G0372 code until after March 31, 2006.
- Submit the E/M service now and bill the G0372 code after March 31, 2006.
The E/M service will be paid now. Note that this is not intended to require that Medicare fiscal intermediaries or carriers split claims submitted with both the E/M and G0372 code. Rather, the physician/provider may choose to submit two separate claims for the individual services.
Providers submitting claims on or after April 1, 2006 must bill the E/M and the G0372 code on the same claim.
Critical access hospitals (CAHs) billing the fiscal intermediary (FI) under Method II have the following options from January 1, 2006, through July 2, 2006, for submitting the G0372 code and the E/M code:
- Submit the G0372 and E/M now on the same claim. Payment for these claims will be held by the FI through July 2, 2006.
- Hold all claims containing the G0372 code until after July 2, 2006.
- Submit the E/M service now and bill the G0372 code after July 2, 2006. The E/M service will be paid now. Note that this is not intended to require the FIs or carriers to split claims submitted with both the E/M and G0372 code. Rather, the physician or treating practitioner may choose to submit two separate claims for the individual services.
Method II Critical Access Hospitals submitting claims on or after July 2, 2006 must bill the E/M and the G0372 code on the same claim.
Background
The Centers for Medicare & Medicaid Services (CMS) published an interim final rule on PMDs to conform its regulations to section 302(a)(2)(E)(iv) of the Medicare Modernization Act (MMA), which is codified at section 1834(a)(1)(E)(iv) of the Social Security Act (SSA). The effective date of the rule was October 25, 2005.
For PMDs, the MMA mandated that:
- A face-to-face examination of the individual be conducted by a physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist; and
- That payment may not be made for a motorized or power wheelchair unless the physician or treating practitioner has written a prescription for the item.
By defining the practitioners allowed to conduct the face-to-face examination, it also effectively removed the current requirement that a beneficiary must be seen by a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology in order to get a power-operated vehicle (POV).
Submission of Medical Record and Prescription
Apart from the MMA requirements, the other key change made by this regulation is a requirement that the physician or treating practitioner must submit pertinent parts of the medical record (in lieu of the Certificate of Medical Necessity (CMN)), along with the prescription, to the durable medical equipment (DME) supplier within 30 days of the face-to-face examination.
A separate add-on payment (an add-on payment to the office visit billed with the code of G0372) was established by the rule to recognize the additional physician work and resources required for submitting pertinent parts of the medical record.
Payment for the history and physical examination is made through the appropriate evaluation and management (E&M) code along with the add-on payment (G0372) which goes to the local Medicare fiscal intermediary or carrier. The PMD claim will go to the local durable medical equipment regional carrier (DMERC).
Appropriations Act
Title II, Section 222, of the Departments of Labor, Health and Human Services, and Education and Related Agencies Appropriations Act, 2006 (H.R. 3010) (the Appropriations Act) was signed into law on December 30, 2005. It states, in part:
SEC. 222. None of the funds made available under this Act may be used to implement or enforce the interim final rule published in the Federal Register by the Centers for Medicare & Medicaid Services on August 26, 2005 (70 Fed. Reg. 50940) prior to April 1, 2006.
Although this section of the Appropriations Act does not allow federal funds to implement or enforce the rule, CMS believes that this section does not affect the validity of the rule. Therefore, CMS is instructing DMERCs and/or DME PSCs that, between January 1, 2006 to April 1, 2006, contractors will only pay PMD claims that satisfy the requirements of section 1834(a)(1)(E)(iv) of the SSA.
Based on the Appropriations Act, CMS is instructing fiscal intermediaries and carriers to hold claims that contain G0372. These claims must be held through March 31, 2006. Carriers will begin to release physician claims for processing on April 3, 2006.
Implementation
The implementation date for this instruction is no later than two weeks after release of CR4372 or March 24, 2006.
Additional Information
For additional information regarding PMD, you may want to review the following MLN Matters articles:
The official instructions issued to your carrier, DMERC, FI, or RHHI regarding this change can be found at http://www.cms.hhs.gov/Transmittals/downloads/R215OTN.pdf  on the CMS Web site.
If you have questions, please contact your Medicare carrier, DMERC, FI, or RHHI at their toll-free number, which may be found at http://www.cms.hhs.gov/apps/contacts/  on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents.
MLN Matters Number: MM4372 Revised
Pub. 100-20, Transmittal #: R215OTN, CR# 4372
Related CR Release Date: March 10, 2006
Effective Date: January 1, 2006
Implementation Date: No later than March 24, 2006
Additional Information Provided by Empire Medicare Services
G0372 Physician service required to establish and document the need for a power mobility device (use in addition to primary evaluation and management code).
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