ASSESSMENT

The assessment is usually performed in patient’s home, with therapist, family, caregivers, and anyone else who wants to have input of the new equipment.  The home and vehicle are assessed to determine what equipment will be functional and usable.  The patient is measured, and the team / group involved brainstorm to determine the goals, and then to apply the most appropriate equipment to meet the patient’s needs.

REPORTS

The rehab supplier usually at this point absorbs all of the information discussed, and starts researching equipment, to match up the most appropriate equipment.  This sometimes marriages one to a dozen different manufacturer products together to come up with the equipment solution.  The rehab supplier then writes up a report, with pictures if necessary, and sends a copy to therapist, physician, and family (if necessary).  The medical professionals use the letter as a guide in medically justifying the equipment for the patient.  If the medical professionals see an item that is not appropriate or forgotten they will contact the rehab supplier to make necessary changes.

DOCTOR CMN  

The CMN (Certificate of Medical Necessity) is a 1-2 page form that is filled out by the supplier with all of the equipment being recommended for the patient; that the physician needs to answer some questions, fill out some of the blanks, and sign the equipment (prescribing the specific equipment).  ---See attached CMN for Power Wheelchair.

We send a copy of the supplier report, patient pictures, and a CMN to be completed, with a postage paid envelope to speed the process.  The important areas of this form for the physician are SECTION B- length of need, and Diagnosis codes.  Section D- signature and date.  

THERAPY REPORT  

The therapist uses their information gained through the assessment, and the suppliers equipment list to write a letter of medical justification for the equipment being recommended.  A new form has been generated to make the process clearer with less room for error. (see mobility evaluation for power wheelchair)  

APPROVAL  

There is certain equipment that is sent to Medicare for approval and certain equipment that supplier inspects all forms for needed information.  This is where the supplier takes  a chance as with exception of Tilt in space manual, Ultra-lightweight wheelchairs, and custom powered wheelchairs (ie. Tilt/recline/stand); the supplier has to ensure all documentation is in order and client is eligible.  Medicare will not give authorization number for chair, or say how much they will pay until after the equipment is ordered, delivered, and claim submitted.  THIS IS WHY MOST PROVIDERS WILL NOT TOUCH MEDICARE BENEFICIARY CHAIRS.  For tilt/recline/stand, or ultra-lightweights there is an approval process to determine eligibility. 

There are further complications here, as many beneficiaries think they have Medicare, but may have an HMO instead.  HMO’s are contracted with only a few providers, and must see appropriate provider.

ORDERING EQUIPMENT  

After approval process, the equipment is ordered from one to a dozen different companies, and when received put in staging area to be assembled.  Usually takes two to four weeks; depending on how custom order is.  

DELIVERING AND FITTING  

After the equipment is assembled, and checked, an appointment is made to visit patient, and therapist to deliver and fit the equipment.  This process places the patient in the chair, all items are inspected, and adjusted.  In some cases the chair needs to return to the shop to make modifications; before patient can take delivery.

SUBMIT CLAIM FOR PAYMENT  

Only after equipment is delivered and signed for can the claim be submitted for payment.  All reports from physician, therapist and supplier are sent to Medicare for claim placement.  Payments from Medicaid can take from one month- to one year to pay completely, depending on how custom equipment is.

 FOLLOW UP  

Most custom chairs require some sort of follow up.  Usually within in a month after deliver, sometimes sooner or later, a visit is set up to check on chair, adjust what is needed.

 HOW DOES MEDICARE’S FEE SCHEDULE WORK

 Medicare has a fee schedule that lists equipment (generally) by codes and offers allowable payment(s) on that code.  Some of the codes have been adjusted to fair market levels and others have not changed for years. 

 To make this clear:  

CODE	DESCRIPTION	MANUF	PART #	PRICE	ALLOW
K0011	Programmable Powered Wheelchair	ANY	ANY	6000- 8000	4848.50
K0115	Custom Molded Back Support	ANY	ANY	1200.00	900.00
E1002	Power Tilt in Space	“	“	5095.00	4113.02
E960	Shoulder Harness	“	“	140.00	90.98

 In the allowable column, these are what Medicare will allow (ceiling payment) for this type of equipment.  Of this listed amount, Medicare will only pay 80% of this price; expecting a secondary insurance to cover the 20% (adding up to the total allowable).

As you can see supplier work on narrow margins and have to be precise on equipment selecting and make few mistakes to remain profitable.

IN THE EVENT OF MEDICAID AS SECONDARY

We face the issue daily of how to adequately assist patients who have Medicare primary and Medicaid secondary insurances.  Medicaid does not pay the 20%; expected to from secondary insurance. 

For beneficiaries who have Medicaid we need to be very careful and watch supplier costs closely; as receiving funds for the chairs can take upto one year to get compensated for.  

So in the equipment selection process, we need to be careful in selecting equipment that closely follows the Medicare allowable guide.  This sometimes infringes on giving the best or most appropriate equipment to the patient.

 WHEELCHAIRS  

As with any item covered by Medicare, they want to pay for the least expensive means to solve patient’s needs.  All wheelchair codes with exception of K0005, K0009 are rental chairs meaning chair is rented to patient.  K5 and K9 chairs are purchased directly for the beneficiary.  

K0001-standard weight wheelchair (hospital grade)  

K0002- hemi-height wheelchair constructed to be lower to the ground with the intention of user to push with feet.  

K0003- Light weight wheelchair, usually only available in limited sizes and configuration  

K0004- Light weight, high strength wheelchair. Usually comes in several configurations,  and reduces strain on user’s shoulders.  

K0005- Ultra-light wheelchair comes in many sizes and dimensions, is much lighter weight, and is usually best choice for patient with shoulder injuries, potential for shoulder injuries, client’s needing aggressive seating, or other need for light weight.

K0009- Custom tilt in space, or other custom wheelchair that cannot be categorized by other code.  Generally used to code tilt and combination recline wheelchairs.

SCOOOTERS

E1230- scooters have a capped allowable of $1922.52.  This amount is paid at 80% under Medicaid, with expectation of secondary to pay 20%.  Medicaid does not cover this code, so if Medicare/Medicaid beneficiary than only 80% would be paid. 

Obviously only certain scooter models and brands can be put through under assignment as scooters range from $2000-$5000.00.

Scooters are used by individuals with good trunk and sitting balance, with good upper extremity strength to enable use of steering tiller.

POWERED WHEELCHAIRS

K0010- Standard Weight Power Wheelchair to be used with limited population.

K0011- Programmable Powered Wheelchair to be used with moderate to severe disabled  population.  These chairs offer programmable electronics to tune the chair to  individual control.  These chairs are more stable bases, and are more adaptable to the needs of this population.

 K0012- Lightweight portable powered wheelchair- this too is a limited use product, designed more for the active, geriatric community.

 K0014- Custom Powered Wheelchair- this code is very limited, as most chairs are already coded K0011.  This would be a chair that is very custom.

   

When deciding on a powered wheelchair, it is important to think long term, only K11, and K14 chairs can allow a later add on tilt/recline or specialty electronics system.

   

MEDICARE # 1 CONCERN:  

The number one concern is that the primary use of the equipment is to be within the user’s residence, and that the equipment being recommended is the least costly solution to the problem.  Medicare doesn’t care about school, work, caregiver ease, etc.    

BENEFICIARY COVERAGE

Medicare has Part A, Part B, and Part C.  Part A is coverage for hospitalization.  Part B is for home medical equipment.  Part B gives the beneficiary the choice of provider.  Part C is when beneficiaries turn their traditional Medicare benefits in for HMO coverage.  Generally Part C beneficiaries will have to look in their book from their HMO and find a provider who is on their list.  HMO's contract with companies who provide oxygen, home care, nursing care, and DME

Assignment- suppliers have the choice to select whether they want to accept assignment or not.  Accepting assignment means they will accept what Medicare and supplement pays for the equipment. 

Non-Assignment- suppliers expect payment on delivery of equipment, and claim will be submitted to insurance provider for reimbursement to beneficiary.

Advanced Beneficiary Notice- suppliers can issue a notice stating that they expect Medicare to deny equipment or of equipment is upgraded from basic equipment under a code, they can expect to beneficiary to pay the difference (this is issued prior to equipment delivery).

 

THE FOLLOWING MUST BE INCLUDED AND ADDRESSED (therapist)

- condition necessitating the use of a powered wheelchair or equipment recommended

- date of onset of condition

- progression of condition and prognosis

- semi-quantitative assessment of strength in extremities

- the presence or absence of increased muscle tone or spasms

- trunk stability and sitting posture

- quantification of patient's ability to ambulate and what assistance (cane, walker, other person, etc) is needed for this (if applicable)

- endurance

- cognitive abilities 

- visual impairments

- description of current equipment, age of equipment, and why it is being replaced (if applicable)

Note: as a matter of technicality, only patients that suffer from severe weakness in upper extremities due to neurological or muscular condition qualify for powered wheelchairs.  There is inherent risk of billing for patients with orthopedic, cardiac or pulmonary conditions, as it is, the carrier's position that these patients have adequate strength to self propel in a manual wheelchair.  Although this guideline may not accurately reflect the patient's condition, the carrier has been affirming this decision in fair hearing.