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Durable Medical Equipment (DME) Bill for Wheelchairs and

By Raymond Fisher,2014-06-30 22:00
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Durable Medical Equipment (DME) Bill for Wheelchairs and

Durable Medical Equipment (DME): Bill for dura bil wheel

    Wheelchairs and Wheelchair Accessories 1

This section contains information about billing for wheelchairs. For general Durable Medical Equipment

    (DME) policy information, refer to the Durable Medical Equipment (DME): An Overview and Durable

    Medical Equipment (DME): Bill for DME sections in this manual.

    Note: Per Title 22, California Code of Regulations, Section 51321(g): Authorization for durable medical

    equipment shall be limited to the lowest cost item that meets the patient’s medical needs.

Wheelchair Group The wheelchair group includes the following items:

    ; Wheelchairs

    ; Wheelchair modifications and accessories

    ; Scooters

    Refer to the Durable Medical Equipment (DME): Billing Codes and

    Reimbursement Rates section of this manual for other items and

    codes reimbursable by Medi-Cal.

Treatment Authorization TARs for codes within the wheelchair group must be submitted to the

    Requests San Francisco Medi-Cal Field Office. See the TAR Field Office

    Addresses section in this manual for details.

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    Documentation Unless otherwise specifically noted, all TARs for the purchase, rental,

    repair or maintenance for items within the wheelchair group must

    have the following documentation attached:

    ; Completed 50-1 TAR form

    ; A copy of the signed physician prescription

    ; A completed and signed DHCS 6181 form (see the following

     “Certificate of Medical Necessity” information)

    ; For listed items: Specific medical justification for each item is

    requested, using either the DHCS 6181 form or additional

    medical documentation, such as physician’s notes or therapist

    documentation relevant to the request.

    Certificate of Medical Providers must complete the applicable DHCS 6181 form when Necessity submitting documentation to support TARs for wheelchairs and

    scooters:

    ; DHS 6181-A: Certificate of Medical Necessity for a Manual

    Wheelchair, Standard or Custom

    ; DHS 6181-B: Certificate of Medical Necessity for a Motorized

    Wheelchair, Custom or Standard

    ; DHS 6181-C: Certificate of Medical Necessity for a Power

    Operated Vehicle (POV) AKA Scooter, Standard or Bariatic

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    Lightweight Wheelchairs Lightweight wheelchairs must be billed with HCPCS code K0003

    (lightweight wheelchair), K0004 (high strength, lightweight wheelchair)

    or K0012 (lightweight portable motorized/power wheelchair).

    Ultralightweight Ultralightweight wheelchairs must be billed with HCPCS code K0005 Wheelchairs (ultralightweight wheelchair).

“Sports” Model The “athletics” or “sports” models of these chairs are not Medi-Cal

    Wheelchairs benefits.

    Authorization A TAR is required for ultralightweight wheelchairs. These chairs may

    be authorized for recipients with a non-ambulatory or limited

    ambulation clinical condition who would qualify for a standard weight

    or lightweight wheelchair were it not for weakness in the upper

    extremities requiring an ultralightweight wheelchair for support

    locomotion.

    The following clinical conditions or other comparable handicaps may

    justify the design characteristics that these chairs offer:

    ; High-level paraplegia or low-level quadriplegia resulting from

    accident, disease or a congenital condition causing upper

    extremity weakness

    ; Other sufficiently debilitating neurologic, neuromuscular and

    musculoskeletal deficits associated with disease states causing

    upper extremity weakness

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Wheel Bearings Replacement wheelchair bearings for both manual and power

    wheelchairs are billed with HCPCS code E2210 (wheelchair bearings,

    any type, replacement only, each). Reimbursement is limited to 12

    bearings per year for manual wheelchairs and 20 bearings per year

    for power wheelchairs.

    Providers must document in the Reserved for Local Use field

    (Box 19) of the claim, or on an attachment to the claim, whether the

    bearings are for a manual or power wheelchair.

    Power Wheelchairs Claims for HCPCS codes E1239, K0010, K0011, K0012 and K0014

    (power wheelchairs) are restricted to repair only and must be billed

     with modifier RB (replacement of a part of DME furnished as part of

     a repair) and include documentation the repair is for patient-owned

     equipment. Claims billed with modifiers NU (purchase) or RR (rental)

     will be denied*. Providers billing for a purchase or rental of power

    wheelchairs must use the most current HCPCS codes.

    * Use of purchase or rental modifiers with wheelchair code K0011 is

    only allowable for an iBOT Mobility System. For more information,

    see Stair-Climbing Wheelchair in this section.

    Note: This policy is effective for dates of service on or after

    November 1, 2007.

    Power Wheelchair Interface HCPCS codes E2312, E2321, E2322, E2327 and E2373 are special

     power wheelchair interface procedure codes. Claims for these codes

     must be billed with modifier NU (new equipment [purchase]) or RR

    (rental) at the time the wheelchair is initially purchased or rented.

    Reimbursement will be the lesser of the amount billed or the

    maximum allowable for modifier NU or RR, as appropriate.

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    Replacement DME modifier KC (replacement of special power wheelchair interface)

    should be used only for the replacement of a power wheelchair

     interface (codes E2312, E2321, E2322, E2327 and E2373) due to the

     following situations:

    ; A change in the patient’s condition

    ; When both the interface and the controller electronics are

    being replaced due to irreparable damage

     Modifier KC with codes E2312, E2321, E2322, E2327 and E2373

    are replacement items not separately reimbursable with the initial

    purchase of power wheelchair base codes K0813 K0816,

     K0820 K0831, K0835 K0843, K0848 K0864, K0868 K0871,

    K0877 K0880, K0884 K0886, K0890, K0891 or K0898.

    Claims for the replacement of these special interface codes

    E2312, E2321, E2322, E2327 and E2373 must be billed with

    modifiers RB/NU/KC (for a patient-owned power wheelchair) or

    RR/KC (for a power wheelchair rental). The modifiers must be

    entered on the claim in that specific order. Reimbursement for the

    replacement of a power wheelchair interface for a patient-owned

    power wheelchair (as identified by the use of modifiers RB/NU/KC

    with documentation regarding the specific power wheelchair and that

    it is owned by the patient) does not include the cost of labor.

    Providers

    may bill code K0739 to be separately reimbursed for labor. Code

    K0739 is not separately reimbursable for the replacement of the

    power wheelchair interface on a rental power wheelchair (modifiers

    RR/KC).

    Reminder: Modifiers are entered on the claim without a preceding

     hyphen, separating slashes or other punctuation.

    Note: Modifiers (including NU, RP, RB and RR) are not required or

    allowed when billing code K0739.

    Reimbursement Reimbursement will be the lesser of the amount billed or the

    maximum allowable as follows:

    HCPCS Rental Rates Purchase Rates

    Code RR RR/KC NU RB/NU/KC

    E2312 $201.67 $257.20 $2,016.71 $2,572.10

    E2321 $158.92 $223.10 $1,589.10 $2,231.00

    E2322 $141.03 $236.26 $1,410.36 $2,362.59

    E2327 $261.24 $342.08 $2,612.38 $3,420.77

    E2373 $ 70.29 $125.83 $ 702.98 $1,258.35

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Power Wheelchair Accessories HCPCS codes E2374 E2376 and E2381 E2397 (power wheelchair

    accessories) may only be reimbursed as purchased replacement

    items for patient-owned equipment. They are not separately

    reimbursable within the same month of purchase of power wheelchair

    codes K0813 K0891. Claims must be billed with modifiers RBNU

    (labor for replacement is allowed). Documentation of the patient-

    owned equipment these accessories are applied to must be included

    in the Reserved for Local Use field (Box 19) of the claim.

    HCPCS code E2377 (power wheelchair accessory, expandable

    controller) may be reimbursed separately with the rental or initial

    purchase of power wheelchair codes K0835 K0891.

    Stair-Climbing Wheelchair The iBOT Mobility System (stair-climbing wheelchair) is a Medi-Cal

     benefit, subject to authorization. Providers must bill using HCPCS

     code K0011 (standard-weight frame motorized/power wheelchair with

    programmable control parameters). Because the iBOT Mobility

    System is not FDA-approved for children, the stair-climbing

    wheelchair is reimbursable only to recipients who are 21 years of age

    or older. California Children’s Services (CCS) authorization is not

    allowable for reimbursement.

     The recipient must have a medical condition that necessitates the use

    of a wheelchair and a medical need for vertical ambulation within the

    home. Recipients whose disability limits them from work and who are

    vocationally eligible (excluding the elderly) must undergo evaluation

    by the Department of Rehabilitation.

    TAR Requirements TARs must be submitted to the appropriate Medi-Cal field office with

    a copy of the signed prescription from a licensed physician trained in

    the use of the wheelchair in accordance with the manufacturer’s

    recommendations. If the recipient is enrolled in the Genetically

    Handicapped Persons Program (GHPP), documentation must be

    submitted with the service authorization request to the GHPP

    program for determination of medical necessity.

    Additionally, a rehabilitation therapist approved by the Johnson and

    Johnson subsidiary, Independence Technology, must have evaluated

    and determined that the recipient has the necessary physical and

    cognitive skills to operate the stair climbing wheelchair. This

    evaluation must be submitted in writing with the TAR.

    Billing Requirement Claims must identify that the use of HCPCS code K0011 is for an

    iBOT Mobility System when billed with modifiers NU (purchase) or RR

     (rental). Claims billed with modifier RB (replacement of a part of

    DME furnished as part of a repair) must include documentation that

    the

     repair is for patient-owned equipment.

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Pediatric Reimbursement for pediatric wheelchair modifications and

    accessories HCPCS codes E2291 E2295 (back or seat, planar or

    contoured) includes a fixed mounting hardware system that attaches

    the seating system, as one unit or two separate units, to the mobility

    base frame, but allows for the unit(s) to be easily removed for folding.

    Adjustable hardware (for example, swing away laterals and swing out

    abductors) is separately reimbursable, using HCPCS code E1028

    (wheelchair accessory, manual swingaway, retractable or removable

    mounting hardware for joystick, other control interface or positioning

    accessory). The maximum number of adjustable hardware items may

    be dispensed on the same date of service.

Positioning Seat Refer to the Durable Medical Equipment (DME): Bill for DME section

    of the provider manual for HCPCS code T5001 (special orthotic

    positioning seat) billing information.

Reimbursement for In compliance with Welfare and Institutions Code (W&I Code),

    Listed Codes Section 14105.48, claims billed for wheelchairs, wheelchair

    accessories and replacement parts for patient-owned equipment

     billed with listed codes are reimbursed the lesser of:

    ; The amount billed pursuant to California Code of Regulations

    (CCR), Title 22, Section 51008.1, or

    ; An amount that does not exceed 100 percent of the lowest

    maximum allowance for California, established by the federal

    Medicare program for the same or similar item

    For more information regarding the maximum allowable DME

    purchase billing amounts, refer to “Net Purchase Price” in the

    Durable Medical Equipment (DME): An Overview section.

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    Reimbursement for In compliance with W&I Code, Section 14105.48, claims billed for Wheelchair “By Report” wheelchairs, wheelchair accessories and/or replacement parts for Codes patient-owned equipment using codes with no specific maximum

    allowable rate (“By Report”) are reimbursed the least of:

    ; Amount billed pursuant to CCR, Title 22, Section 51008.1, or

    ; Manufacturer’s purchase invoice (cost) amount, plus a 67

    percent markup, or

    ; The percentage of the Manufacturer’s Suggested Retail Price

    (MSRP), as follows:

     85 percent of the MSRP for unlisted wheelchairs, wheelchair

    accessories and/or replacement parts is allowed if the

    provider documents on the claim that (s)he has on staff,

    either as an employee or independent contractor, one of the

    following qualified rehabilitation professionals and that

    qualified rehabilitation professional was directly involved in

    determining the specific wheelchair equipment needs of the

    patient and directly involved with or closely supervised the

    final fitting and delivery of the wheelchair:

    ; Rehabilitation Engineering and Assistive Technology

    Society of North America (RESNA)-certified technician

    ; Certified Rehabilitation Technology Supplier (CRTS)

    ; Licensed California physical therapist

    ; Licensed California occupational therapist

     Reimbursement of 80 percent of the MSRP, if the claim

    does not provide documentation that the provider employs

    or contracts with a qualified rehabilitation professional as

    noted above.

    For more information regarding the maximum allowable DME

    purchase billing amounts, refer to “Net Purchase Price” in the

    Durable Medical Equipment (DME): An Overview section.

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    Documentation Requirements Claim submissions for unlisted wheelchairs, wheelchair accessories

    and replacement parts for patient-owned equipment, require the

    following information:

    ; For dates of service on or after September 1, 2006, the MSRP

    (a catalog page) must be an amount that was published prior to

    June 1, 2006. If the item was not available prior to

    June 1, 2006, attach a manufacturer’s purchase invoice and

    the catalog page that initially published the item and the MSRP,

    and complete the Reserved for Local Use field (Box 19) with

    the date of availability. For dates of service prior to

    September 1, 2006, the MSRP must be published

    prior to August 1, 2003.

    ; Item description

    ; Manufacturer name

    ; Model number

    ; Catalog number

    ; The reason a listed code was not used

    ; If applicable, completion of the Reserved for Local Use field

    (Box 19) with the name of the employed or contracted qualified

    rehabilitation professional

    Claims submitted with a manufacturer’s purchase invoice must

    include an MSRP if the provider is requesting reimbursement at the

    invoice amount plus a 67 percent markup.

    Billing Requirements Unlisted wheelchair or wheelchair accessory items are billed with HCPCS

     code K0108 (wheelchair component or accessory, not otherwise specified).

     Providers must itemize the equipment in the Reserved for Local Use field

     (Box 19) of the claim or on an attachment to the claim.

    If more than one item requires billing with code K0108, providers enter the

    code on one claim line and indicate the total number of items being billed in

    the Days or Units field (Box 24G).

    In addition, reimbursement for code K0108 requires a claim attachment

    (catalog page and/or invoice) showing the items being billed. Providers

    must handwrite the claim line number (for example, “Line 1”) next to each

    item being billed with code K0108.

    Reminder: Items approved on separate Treatment Authorization

    Request (TAR) forms must be billed on separate

    claim forms.

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    Scooters Scooters are generally billed with HCPCS code E1230 (power

    operated vehicle [three- or four-wheel non-highway] specify brand

    name and model number). However, scooters that do not match the

    descriptor for code E1230 should be billed with HCPCS code K0014

    (other motorized/power wheelchair base). Code K0014 requires prior

    authorization and is reimbursed “By Report.”

     Claims for HCPCS codes E1230 and K0014 are restricted to repair

     only and must be billed with modifier RB (repair). Claims must

    include

     documentation that the repair is for patient-owned equipment. Claims

     billed with modifiers NU (purchase) or RR (rental) will be denied. Any

    providers billing for a purchase or rental of power-operated vehicles

    must use the most current HCPCS codes.

    Note: This policy is effective for dates of service on or after

    November 1, 2007.

    Options and Accessories Power operated vehicles billed with code E1230 include all options

    and accessories that are provided at the time of initial purchase or

    within 30 days including, but not limited to, batteries, battery chargers,

    seating systems, etc.

    Claim Denials Claims that do not include all required documentation will be denied.

    Claims billed with an unlisted wheelchair HCPCS code (K0009,

    K0014 or K0108) when a listed HCPCS code is available will be

    denied.

    Note: Providers must supply and bill for the specific wheelchair

    (manufacturer and model) that was approved by the field office

    on the TAR.

    Repair and Maintenance For information about repair and maintenance of wheelchairs, see

    “Repair or Maintenance of Equipment” in the Durable Medical

    Equipment (DME): An Overview section in this manual.

    Pricing Discounts Only discounts known to the provider at the time the claim is

    submitted will be used when pricing claims.

2 Durable Medical Equipment (DME): Bill for Wheelchairs and Wheelchair Accessories August 2009

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