Documenting Direct In-person Involvement of the ATP for CRT
CMS has added the requirement for direct, in-person involvement by an ATP into the Local Coverage Determinations (LCDs) for a number of complex rehab technology (CRT)items. Specifically the LCDs state that these products must be “provided by a supplier that employs a RESNA-certified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient”. The devices that now include this requirement are: Group 2 power wheelchairs with single or multiple power options; all Group 3, Group 4 and Group 5 power wheelchairs; power assist;ultra lightweight manual wheelchairs; and tilt-in-space manual wheelchairs. Although this criteria has been in policy for some of these products for nearly 5 years, there is still confusion as to how this should be documented, since there has been no specific direction from CMS.
Let’s start first with what we know is not acceptable. It is definitely not okay for an ATP to review and sign-off on the work of a non-ATP who has assessed the client and documented the equipment recommendations. The ATP must be the one who actually performed an in-person assessment. This means that in cases where there is only one ATP employed by a company, that ATP must handle all of the evaluations for these specific products. It is also not sufficient for the ATP or the therapist to merely write an attestation that the ATP was present at the clinical evaluation, or for the ATP to just concur with and sign the therapist’s documentation. The ATP must provide some sort of evidence of his/her participation. It’s just like math homework…..you cannot just give your answer, you must also show your work.
Now let’s look at some basic “Do’s” for the ATP documentation. First, it should beproperly titled. The ATP documentation is not a clinical document and, as such, should not be confused with the clinical evaluation from the therapist. Titles such as “Letter of Medical Necessity”, “Seating and Mobility Evaluation”,“Postural Evaluation”, and so forth should not be used. More appropriate titles might include “Technology Assessment for Seating and Mobility” “ATP Technology Assessment”, ATP Contact Note”or something similar. These titles clearly indicate that this is the technology assessment from the ATP (supplier).
Each page should be numbered (i.e., pg 1 of 3), the client’s name should appear at top of the first page (or better yet, every page) and the date of the exam should be clearly identified. The handwriting should be legible, the information should be organized and unfamiliar abbreviations and/or profession-specific lingo should be avoided as much as possible. At the end of the document, the ATP should sign and date it. If others sign the document in concurrence,it should be clear that they are merely agreeing with the results and are not the author/assessor. Before or after every signature the person’s name should be legibly printed. The ATP can also list his/her RESNA certification number on the document and include a photocopy of his/her RESNA certificate in the file.
Any format can be used as long as it includes the pertinent information. The document could be a form with check boxes, a narrative, or(better yet) a combination of the two. The information in the document should basically describe what the ATP did and the results of the assessment. This is the information that the ATP gathers during a client interview, while observing the therapist in the clinical evaluation, while working with the therapist to match clinical needs to product parameters, while identifying products that will provide these parameters, while obtaining anatomical measurements, during equipment simulations and trials, during the home assessment and/or while conducting final fittings, modifications and training. Suggestions for information that might be included in the documentation is outlined in the sections below.
This section could provide the client’s name,diagnosis, and a very brief history of the seating/mobility limitation. It might also include the names of others involved in the client’s care and equipment prescription (i.e., caregivers, therapist(s), physician).
A complete description of the client’s primary mobility device should include the type, age and condition of any current ambulatory devices and/or the type, manufacturer, model, age and condition of any current wheelchair, cushion and back support. Dimensions such as seat width, seat depth, seat to floor height and back height can be included, as well as descriptions of any pertinent options and accessories. Any other mobility equipment that the client has at home should also be listed.
The reason for the need for new equipment should be identified. If there has been a change in medical and/or functional status,this should be described along with the reasons as to why the current equipment can no longer meet the client’s needs, the effect on posture and mobility of the current equipment and/or what the client is no longer able to do. It is also a good idea to verify that the current equipment cannot be modified, added to or reconfigured in order to meet the new needs. If new equipment is required because the old is in a state of disrepair, the items or parts that are broken and cannot be repaired should be listed. It is also a good idea to provide a cost analysis for the parts and labor that would be needed to bring the product back into working order.
If the ATP is the one to obtain the client’s anatomical measurements, these can be included in his/her documentation,preferably along with a measurement chart or graphic. This can help to demonstrate the inappropriateness of current equipment dimensions and verify the need for different sizing, especially if non-standard dimensions are now required.
Results of Simulations andTrials
The assessment and provision of any CRT product should include some kind of equipment trials and/or simulations. A description of these exercises along with their results is perfect for inclusion in the ATP documentation. For trials in a manual wheelchair, there could be a description of the type of wheelchair trialed, any adjustments, configurations and/or modifications that were implemented during the trials, any specific features and options that were used and their results on mobility and function. Pertinent information might include whether or not the person was able to self-propel, the distance propelled, how propulsion improved in the trial equipment compared to the current equipment and so forth. Similar information would be included for trials in a power wheelchair, such as the type of wheelchair,any specific programming and electronic features that were used, the type of joystick or alternative control that was used, any power seating that was needed and the functional results.Finally, the seating should be described, including features of the seat and/or back base, any secondary supports and their results on posture, mobility and function.
The last section could include the equipment recommendations and their justifications. A list of the base product and all required options and accessories could be provided as a 2-column chart with one column listing the specific item along with the manufacturer and model, while the other column gives the medical justification. The justifications should describe why the feature is needed and what it will accomplish.They should be as specific as possible for that particular person and not just “cookie cutter” phrases. In some cases, it might be necessary to indicate why a lower cost alternative will not meet the person’s needs.
The home assessment can be performed by the clinician,ATP, rehab tech or delivery person. However, if it is carried out by the ATP, it is another way to document direct involvement. The information gathered might be recorded in a section of the technology assessment or as a separate home assessment form. The home assessment should give evidence that the recommended (provided) equipment can be safely and appropriately used in the person’s home.
The home assessment should include the client’s name, address and the date of the assessment. Other information might include:
·The type of structure should be described (one level or multi-level house or apartment, mobile home, assistive living, independent living, group home, long term care)
·Accessibility into and out of the home (steps, stairs, ramps, sliding glass doors, elevator)
·Indoor surfaces (linoleum, low carpet, high carpet, tile, stone)
·Outdoor terrain (pavement, gravel, grass, dirt, stone, brick).
·The accessibility of pertinent rooms as described by hallway width, doorway width, thresholds, maneuverability within the room, and so forth.
·Recommendations and plans for modifications and renovations
·Evidence that there commended product (or a reasonable facsimile) was successfully trialed in the home and could be maneuvered in and out of all necessary spaces.
·Means of transportation and any transportation needs.
CMS has not provided specific guidelines as to what should be included in the ATP’s documentation to show direct, in-person involvement. This isn’t necessarily a bad thing, since it gives the ATP leeway to document exactly what he/she did during that assessment. And although taking the time to complete a well-organized informative assessment form is one more thing on the ATP’s “plate” it can result in a number of benefits. First of all it provides Medicare (and other funders?) with evidence of the required in-person involvement.Secondly, it demonstrates the importance and extent of the supplier’s role in the assessment process for CRT. By emphasizing the complexity of the service delivery for CRT vs standard DME, it can help to increase the credibility and professional perception of the ATP. And perhaps someday, it might help to push the funders to actually reimburse the ATP for their assessments, demos,simulations and follow-ups. By consistently documenting what is done during a wheelchair assessment, the ATP can demonstrate his/her role in the provision process. As ATPs, it is time to raise the bar and create complete, informative and consistent documentation to demonstrate the importance of the technology assessment.
For examples of forms for both the ATP technology assessment and the home assessment go to www.usrehab.com, click on “Resources”, then “Peggy Walker”,then “MAE Tips”. Look for the documents titled “ATP Technology Assessment Form”, “Home/Environmental Assessment Form” and “Assistive Technology Professional (ATP) Contact Note”.
Elizabeth Cole, MSPT, ATP