Reimbursement Update: A Medicare Checklist

• By W. David Yates, Roger E. Meiners
• Nov 01, 2003

With the current goings on in the power mobility market caused by unscrupulous providers paying beneficiaries to accept scooters and offering free power mobility products on television, the Center for Medicare and Medicaid Services (CMS) has enacted Operation Wheeler Dealer. What these fraudulent providers have caused, apart from a moratorium on new NSC supplier numbers, is even tighter scrutiny of power mobility claims. This tighter scrutiny will include, by association, accessories billed along with both power and manual mobility claims. This article will review the more common accessories billed in conjunction with mobility claims and Medicare's criteria for their coverage. We, as an industry, can only hope that once Tom Scully and CMS finish coming down incredibly hard on these alleged criminals, we can get back to business as usual in the power mobility market.

To begin, let's look at the underlying reason for Medicare coverage of either a manual or power mobility base. Medicare states that for a manual or power wheelchair base to be considered medically necessary the patient would be confined to their bed or a chair (piece of furniture) within their home. So, before we begin discussing adding accessories to a Medicare beneficiary's wheelchair, we must insure that the patient meets this baseline criteria for coverage of their wheelchair base. If your patients do not meet this requirement, stop reading this article right now and move on to the next article. Your accessories have the same chance of being covered as your chances of encountering a snowstorm in the Bahamas. If they meet this criteria, read on.

Let's start with those accessories that require a Medicare Certificate of Medical Necessity (CMN). Claims for these accessories must be accompanied by a CMN listing these items in Section C (along with their HCPCS code(s) listed in Section A). If these items are provided after the base is dispensed and billed, you must gather a Revised CMN outlining the accessories not included on the Initial CMN. The following 10 items fall into this category:

K0016: detachable, adjustable height armrest (complete assembly)

K0017: detachable, adjustable height armrest (base)

K0018: detachable adjustable height armrest (upper portion)

K0020: fixed adjustable height armrest (pair)

K0046: elevating legrest (lower extension tube)

K0047: elevating legrest (upper hanger bracket)

K0048: elevating legrest (complete assembly)

K0053: elevating footrest (articulating / telescoping)

K0195: elevating legrest (pair used with capped rental chairs)

The following are some of the more common wheelchair accessories and the conditions which must be in place for their coverage. Please keep in mind that for any accessory to be considered for coverage under Medicare, the accessory must be necessary to assist the patient to function within their home or to perform instrumental activities of daily living (ADL). Items or accessories that assist the patient in leisure or recreational activities are not a covered benefit of Medicare. Products commonly ordered, dispensed and covered include:

Full Reclining Back

- is covered if the patient spends at least two hours per day in their wheelchair and has one or more of the following conditions: quadriplegia, fixed hip angle, trunk or lower extremity cast or brace requiring a reclining back for positioning, excess extensor tone of the trunk muscles or a need to rest in a recumbent position two or more times per day where there is difficulty transferring between their wheelchair and their bed.

Full Elevating Leg Rests (ELR)

- are covered if the patient has a musculoskeletal condition or a cast or brace that prevents 90 degree flexion of the knee, significant edema of the lower extremities or if they meet the requirements for a full reclining back.

Full Adjustable Height Armrests

- are covered if the patient spends at least two hours per day in their wheelchair and requires an arm height that is different than that available using nonadjustable arms.

Full Non-standard seat width, depth or height are covered if the base that is ordered by the physician is at least two inches greater or less than a standard option or if the patient's dimensions justify the need for the chair's deviated dimensions.

Full Safety Belts and Pelvic Straps

- are covered if the patient has weak upper body muscles, upper body instability or muscle spasticity that would require the use of a belt or strap for proper positioning.

Full Arm Troughs

- are covered if the patient has quadriplegia, hemiplegia or uncontrolled arm movements.

Full Anti-Rollback Devices

- are covered if the patient self-propels and requires the device due to ramps the patient must ascend.

Full Anti-tippers and Wheel Locks

- are covered by Medicare without any additional documentation. They are, however, included in the reimbursement for power wheelchair bases.

Full Batteries for power wheelchairs

- can be billed up to two at a time and are not included in the reimbursement for the wheelchair base. They are, however, included in the allowable for a POV (scooter) but can be billed for replacement for a POV.

Full Battery Chargers

- are included in the allowable for the power wheelchair base although they can be reimbursed when it is billed as a replacement. Dual mode chargers are not a covered Medicare benefit and will be reimbursed at the least costly single mode alternative.

One Arm Drive Attachment

- is covered if the beneficiary self-propels with only one hand and the need to do so is expected to last at least six months.

Reinforced Back or Seat Upholstery

- is covered as a separately billable item only for use in power wheelchairs and if the patient weighs more than 200 pounds. Manual wheelchair bases from K0001 to K0005 are not eligible for reinforced upholstery and when used in conjunction with a heavy-duty (K0006) or an extra heavy-duty (K0007) manual chair, the reinforced upholstery is included in the allowable for the wheelchair base.

Solid Seat Inserts

- are covered if the patient is spending at least two hours per day in the wheelchair.

Hook-on Headrest Extensions

- are covered for patients with weak neck muscles and need the headrest for support or meet the criteria and are using a reclining back on their chair.

Custom fabricated back or combined back and seat modules- are covered if:

1. the patient spends at least two hours per day in their wheelchair;

2. the patient has a significant spinal deformity or severe weakness of the trunk muscles;

3. the patient's need for prolonged sitting tolerance, postural support to permit functional activities or pressure reduction cannot be met adequately by a prefabricated seating system.

Swingaway detachable footrests

- are included in the allowable for a wheelchair base and should only be billed when they are provided as replacements.

Miscellaneous options and accessories

- not covered by an officially assigned HCPCS code need to be billed to the DMERC using the K0108 billing code. When using the K0108 billing code you will need to provide Medicare with a narrative description of the item, the manufacturer of the item, the brand name and model number of the item (if applicable) and the information to justify the medical necessity of the item. Information to justify the medical necessity of the item may include the patient's diagnosis, the patient's abilities and limitations related to the equipment, the expected duration of the patient's condition, the patient's prognosis or past experience using similar equipment (if applicable). If you are unsure whether an item is covered by an established HCPCS code or would need to billed with the K0108 code, contact Statistical Analysis Durable Medical Equipment Regional Carrier (S.A.D.M.E.R.C) at (877) 731-1326. They are available Monday through Friday from 9 a.m. until 4 p.m. except Wednesdays when they are available until 6 p.m.

When billing for all accessories at the time you are submitting the claim for the wheelchair base, make sure the accessories are submitted on the same claim as the wheelchair base. If you are submitting the claim on a paper HCFA-1500 and the claim requires multiple claim forms, do not subtotal each page. Carry the total to the last page in the claim sequence.

When billing options or accessories for replacement, be sure to add the RP modifier to your billing and document the medical necessity of the item being replaced. You also need to indicate (either on paper for HCFA-1500 claims, or in the narrative record for electronic claims) the manufacturer and model name of the wheelchair base to which you are replacing the accessories, along with the date Medicare paid for the purchase of the chair.

This article originally appeared in the November 2003 issue of HME Business.