WASHINGTON -- Medicare's proposal to require a face to-face visit before a physician can prescribe a wheelchair or other durable medical equipment is annoying and inconvenient, several physicians said at a meeting of the program's Practicing Physicians Advisory Council.

"If I take care

of stroke patients in the hospital and they leave with a walker, then progress to a cane, do they have to come back for a face-to-face visit before I can prescribe a cane?" asked Laura Powers, M.D., a Knoxville, Tenn., neurologist and member of the council, which advises Medicare on issues of interest to physicians.

Herb Kuhn, director of the Center for Medicare Management at the Centers for Medicare and Medicaid Services, said that the idea behind the regulation was to deter durable medical equipment (DME) supplier fraud. "We're looking for continuity of care. If a person had a relationship with a physician and had seen that physician over a period of time and the physician knew they were ultimately going to need a power wheelchair, they could make that prescription before then."

Under the proposed rule, a face-to-face examination would be required "to deter mine the medical necessity of durable medical equipment, orthotics, and prosthetics." However, the exam must be "for the purpose of evaluating and treating the patient's medical condition and not for the sole purpose of obtaining the prescribing physician's or practitioner's order for the [equipment]."

Don Thompson, director of the division of ambulatory services at CMS, told the council members that the agency "doesn't want to create an unnecessary burden for physicians," even as it is trying to combat DME fraud.

Council chair Michael Rapp, M.D., expressed concern that Medicare would not pay for evaluations performed solely to determine whether the patient needed a power wheelchair, despite the fact that "that might be an extensive evaluation." Mr. Kuhn responded that he did not think the agency would want to get out of paying for such an extended visit, "but it per haps requires some clarification and comment."

Although wheelchair fraud is at the heart of the agency's fraud concerns, the CMS Physician Regulatory Issues Team (PRIT) is looking at expanding the categories of specialists permitted to prescribe power wheelchairs. Currently only physiatrists, orthopedic surgeons, neurologists, or rheumatologists can prescribe power wheelchairs, and primary care physicians and other specialists can prescribe them only if one of those specialists is not readily available--that is, if they are located more than a day's round trip from the beneficiary's home--or if the patient is too sick to travel to a specialist.

"I think we're coming to a good resolution on this with our proposal to allow physicians of any specialty to prescribe them," said William Rogers, M.D., PRIT director. "It really wasn't the best time to be broadening the number of specialties that can do it, but it is the right thing to do."