esMD eDoC – Automating PMD Coverage October 23 th, 2013

Over View of the PMD Benefit Coverage Over View of e-Clinical Template ICD-10 Codes supporting eDoC Agenda

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

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) 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 11

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) –G 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

International Classification of Functioning, Disability and Health (ICF) b - BODY FUNCTIONS s - BODY STRUCTURES d - ACTIVITIES AND PARTICIPATION e - ENVIRONMENTAL FACTORS 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 FUNCTIONS b750-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 Links esMD Initiative: esMD Program: Contact Information Robert Dieterle – esMD Initiative Coordinator Sweta Ladwa – ESAC Dan Kalwa – CMS Mark Pilley – Co Lead Dr. Viet Nguyen – Co Lead 22