Fact Sheets

UPDATE: IMPLEMENTATION OF MEDICARE'S POWER MOBILITY DEVICE (PMD) RULE

Summary:   This fact sheet provides an update on the implementation of Medicare’s Power Mobility Device (PMD) Rule, in light of the implications of the subsequent appropriations legislation on the rule’s implementation.

The Medicare Modernization Act of 2003 (MMA) required the Centers for Medicare & Medicaid Services (CMS) to revise its requirements for prescribing and paying for power mobility devices (PMDs), including power wheelchairs and power operated vehicles (power scooters).   CMS implemented these changes through an interim final rule, which was effective in October 2005.  However, Congress has directed Medicare, through the appropriations bill that includes funding for the Medicare program, to wait until April 1, 2006 to implement the rule.  Therefore, CMS is asking physicians and treating practitioners to hold certain claims until April 1, 2006.

Background:   Section 302 of the MMA conditioned Medicare payment for power wheelchairs on a physician or other treating professional (including a physician assistant, a nurse practitioner, or a clinical nurse specialist), conducting a face-to-face examination of the individual.  In addition, the MMA required that the physician or treating professional provide a written prescription for the item.  The MMA also eliminated a requirement that a specialist in physical medicine, orthopedic surgery, neurology, or rheumatology examine a beneficiary before prescribing a power scooter. 

CMS published an interim final rule to conform Medicare regulations to the MMA requirements.   The effective date of the rule was October 25, 2005.

Apart from the MMA requirements, the other key changes made by this regulation include 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.  The rule provided for a separate payment of $21.60 in addition to the payment for the office visit to recognize the additional physician work and resources required for submitting pertinent parts of the medical record.

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:

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.

Implementation:   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.  Until April 1, 2006, Medicare will pay PMD claims based on the standards enumerated in section 302 of the MMA.  Due to the Appropriations Act, CMS will be unable to adjudicate claims that contain the add-on payment (G0372) until after April 1, 2006. Therefore physicians and treating practitioners have several options for submitting the G0372 and the Evaluation and Management (E/M) Code:

• Submit the G0372 code and E/M now on the same claim.  Payment for these claims will be held until after April 1, 2006.
• Hold all claims containing the G0372 code until after April 1, 2006.
• Submit the E/M service now and bill the G0372 code after April 1, 2006.   The E/M service will be paid now and the G0372 code will be paid after April 1, 2006. 

After April 1, 2006, physicians and treating practitioners must bill the E/M and the G0372 code on the same claim.

Outreach:   CMS will continue to educate physicians and treating practitioners (via MedLearn Matters articles) on their critical role of prescribing PMDs.  CMS will also issue instructions to the Durable Medical Equipment Regional Carriers (DMERCs) that are responsible for processing PMD claims to promote consistent claims processing during this time period.  In addition, the DMERCs will issue articles providing guidance to DME suppliers on the documentation needed to establish medical necessity of the prescribed equipment.