Medicare Paid Suppliers for Power Mobility Device Claims That Did Not Meet Federal Requirements for Physicians' Face-to-Face Examinations of Beneficiaries

Federal law and regulations require that before a power mobility device (PMD) is covered under Medicare, a physician must conduct and document a face-to-face examination of the beneficiary and write a prescription for the PMD. In 2005, CMS introduced the optional Healthcare Common Procedure Coding System code G0372 for a physician to establish and document the need for a PMD. We refer to a physician claim with the G0372 code as a "G-code claim."

For PMD claims with corresponding G-code claims, Medicare paid the PMD claims in accordance with Federal requirements for face-to-face examinations of beneficiaries. Of the 100 sample claims, we reviewed 94 and concluded that all met the requirements. For six claims, the physicians could not be contacted, and we treated these six claims as non-errors.

For PMD claims without corresponding G-code claims, Medicare did not always pay the PMD claims in accordance with Federal requirements for face-to-face examinations of beneficiaries. Of the 100 sample claims, 53 claims met the requirements, but 47 did not. On the basis of physician interviews, we concluded that many physicians were unfamiliar with the G0372 code. After reviewing medical records, we also concluded that many physicians were not aware of the documentation requirements for face-to-face examinations. Furthermore, CMS did not require durable medical equipment (DME) Medicare contractors to match suppliers' PMD claims to physicians' G-code claims to identify PMD claims that were at high risk of being unallowable. On the basis of our sample results, we estimated that, of the $87.4 million of high-risk claims that we reviewed, Medicare paid approximately $35.2 million in 2010 for PMD claims that did not meet Federal requirements.

We recommended that CMS (1) adjust the 47 sample claims representing overpayments of $115,000 to the extent allowed under the law, (2) require physicians to use the G0372 code when prescribing PMDs, and (3) require Part B Medicare contractors to educate physicians on the use of the G0372 code and the documentation requirements for face-to-face examinations.

After the second and third recommendations have been implemented, any PMD claims without corresponding G-code claims would be at high risk of overpayment. Therefore, to help realize future savings for Medicare, we recommend that CMS require DME Medicare contractors to match suppliers' PMD claims to physicians' G code claims, which would help these contractors to identify and review suppliers with a large number of high-risk PMD claims (i.e., those without corresponding G-code claims) and could have saved an estimated $35.2 million for the 1-year period we reviewed. CMS partially concurred with our first and fourth recommendations and did not concur with our second and third recommendations.