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Coding:

SECURE WHEELCHAIR PAYMENT UNDER NEW CATEGORY

Published on Mon May 19, 2003

A new fix for tilting wheelchair billing appears to solve one problem, but it also brings up even more reimbursement headaches that could deprive suppliers of payment.

The Centers for Medicare & Medicaid Services will move E1161 (manual wheelchair, includes tilt in space) from the capped rental category to the inexpensive or routinely purchased category July 1, according to a CMS official speaking at the May 7 Open Door Forum for home health and durable medical equipment. CMS also will shift codes for pediatric wheelchairs, E1231 through E1238, to the purchase category, the agency says in May 9 program memorandum AB-03-071.

CMS had assigned E1161 to the capped rental category Jan. 1, but data suggests the wheelchair is more often purchased, the CMS official said - thus, the change in category.

Until it can make the category switch in July, DME suppliers can bill for the E1161 wheelchairs by using K0009 (other manual wheelchair), a miscellaneous code, the CMS official directed.

However, a caller noted that DME regional carriers haven't been allowing suppliers to bill for the chairs using K0009. The CMS official assured participants that as of May 7, the DMERCs would accept the code for the tilting wheelchairs.

Once CMS makes the category change in July, billing for the items will be much easier, cheers Peggy Walker, billing and reimbursement advisor for Waterloo, IA-based U.S. Rehab. Having a set fee schedule amount for the E1161 versus the individual consideration DMERCs would assign under K0009 will be a boon, Walker tells Eli.

But right now, a number of suppliers are facing big billing problems for the items, warns Walker, who formerly worked for DMERC Palmetto GBA's medical review department.

First off, it is unclear what suppliers should do to obtain reimbursement for K0009 claims the DMERCs have rejected. The CMS official said in the forum that the agency is researching what to do about K0009 claims submitted between Jan. 1 and May 7 and will issue guidance on the matter soon.

The K0009 confusion is typical of the miscommunication between CMS and the DMERCs, notes consultant Roberta Domos with Redmond, WA-based Domos HME Consulting. And suppliers shouldn't count on being able to use K0009 until they get approval directly from carriers, Walker adds, since sometimes it takes a while for instructions to "trickle down" to the DMERC level.

An even bigger problem will be claims suppliers have submitted under the capped rental category, Walker says. When tilting wheelchairs switch over to the purchase category in July, suppliers with capped rental claims will be left hanging, she fears.

Under capped rental rules, patients can choose to purchase the item in the tenth month, not the second through sixth month that suppliers would be on when the July 1 effective date rolls around, Walker says. "People who have billed [the wheelchair] as a capped rental won't be able to work it out" and will be left without payment, she worries.

"This will be a claims processing nightmare," since DMERCs can't override capped rental edits, she forecasts.

Certificates of medical necessity for tilting wheelchair claims also might be a problem, Walker points out. Information on CMNs should match information on the claims, which could cause a major paperwork burden for suppliers.

Wait for Further Instruction Before Billing, Expert Advises

Suppliers will have to wait on the final solution from CMS and the DMERCs. Providers should watch for forthcoming information in program memos, Walker advises.

Until that information appears, Walker is advising members of U.S. Rehab, a network of re-hab technology suppliers, to hold off on billing for these wheelchairs.

Other DME issues covered in CMS' Open Door Forum include:

  • Diagnosis codes. CMS has made it clear suppliers don't need to obtain new physician orders or CMNs when a diagnosis code is updated, an official said in the call.

    The Health Insurance Portability and Accountability Act requires suppliers to submit the most up-to-date, specified diagnosis code for a patient on an electronic claim, but that code doesn't have to match up with the code on orders and CMNs, a recent program memo explained (see Eli's HCW, Vol. XII, No. 15 article "Diagnosis Coding").

    The memo "goes a long way in addressing the issues the industry has brought up in the last couple of months," the CMS source insisted.

  • DME repairs. CMS is in the process of promulgating instructions on whether a doc's order or a CMN is necessary for patient-owned DME repairs, an official said in the forum. The agency is having "heated discussions internally" about the issue, the source admitted.

    The repair issue gets even more complicated when it's a component of a larger item such as a wheelchair that needs repair, a caller emphasized in the question-and-answer portion of the forum.

    Often suppliers will use one code to purchase a chair and all its components. When the supplier later replaces a part and bills for the service, "it's the first time that code is billed" for the component, the caller pointed out.

    CMS will take the issue into consideration when issuing the new guidance, the official said.

     

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