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Medicare Compliance & Reimbursement

DME:

New Codes, More Changes For Power Wheelchairs

Published on Fri May 07, 2004

Planned bright lines should help suppliers figure out coverage.

The Centers for Medicare & Medicaid Services is on to the next stage of its battle against power wheelchair fraud and abuse. And that stage will contain some of the suggestions wheelchair suppliers have made in the last eight months under Operation Wheeler Dealer.
 
One major part of the plan: expanding the coding choices for power wheelchairs. "Currently, most power wheelchairs are billed under a single code (K0011), for which Medicare has set a single ceiling amount of $5,296.50, even though different models of these wheelchairs have substantially different market prices," CMS notes in a release.

Now, CMS will work with a national coding panel "to develop a new set of codes that better describe the wheelchairs currently on the market," it says. The agency then will develop new payment ceilings for those individual, new HCPCS codes.

Suppliers had suggested this move in a special listening session Open Door Forum CMS held on the power wheelchair issue March 3.

Bed- and Chair-Confined Definition Gets Overhaul

CMS also appears to be responding to suppliers' complaints that the guidelines for wheelchair coverage are way too fuzzy, putting suppliers on the financial line for whether beneficiaries' equipment is covered. The industry called for so-called bright lines on ambulatory status and the definition of bed- or chair-confined in another March 31 forum on the wheelchair issue.

Now CMS says it will develop more detailed coverage guidance by bringing together clinicians from the Department of Health and Human Services and other government agencies. The panel, which will include CMS' chief medical officer, will "refine and describe the conditions that are associated with the current coverage definition."

And particularly welcome by the industry, the group will "develop draft guidance for determining whether a patient meets the definition of 'bed or chair confined,'" CMS says in a release.

Other steps CMS plans to take in its wheelchair initiative include:

  • Regulation. CMS will "address requirements for ordering mobility equipment through a proposed regulation," it says. The reg will implement some provisions of the Medicare Modernization Act passed last December.

  • Supplier standards. The agency finally has set a timeline for implementing the new quality standards required in MMA. CMS will finalize the new standards by next fall.

  • Bidding. Power wheelchairs will be one of the items included in the competitive bidding program required in MMA. Under bidding, CMS will develop a proposal for a mandatory supplier accreditation program.

  • Supplier numbers. The National Supplier Clearinghouse will continue to scrutinize applications for enrollment, CMS promises.

    Operation Wheeler Dealer has recovered $84 million in fraudulent claims for power mobility products nationwide, CMS crows. The durable medical equipment regional carriers have referred about 155 potential fraud cases, representing 265 suppliers, to law enforcement since September 2003.

    "About 10 percent of these cases have been closed already, indicating a very aggressive approach by law enforcement," CMS says.

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