Article Detail - JA DME

Posted June 10, 2011

Effective for items provided on or after January 1, 2011, standard power wheelchairs (K0813 - K0831, K0898) must be furnished on a monthly rental basis like other capped rental durable medical equipment (DME). The following are questions and answers from suppliers regarding application of the Power Mobility Devices medical policy and CMS payment policy rules to rented power wheelchairs.

Short-term use

1. When standard power wheelchairs (PWCs) are provided on a rental basis, can they be covered for short-term indications?
   Response: No. The change in the payment policy status for PWC does not change the policy statement that PWCs are not covered for patients with short term, reversible conditions.
2. A short-term rental would occur if the beneficiary were to pass away in the second month of the rental period. Will a short duration in billing signal that a short-term rental has occurred and flag the claim for review?
   Response: If all the criteria are met for coverage of a PWC and the initial rental months are paid but the beneficiary dies within the first 3 months or the patient goes into a nursing home on a permanent basis during the first 3 months, that does not affect coverage of those initially paid rental months.

Change of residence

3. Is it advisable for the supplier to document in their records that they have contacted the beneficiary and confirmed that the beneficiary is able to use the PWC they are renting in their new residence?
   Response: There is no requirement for a supplier to reassess the home in the event that a beneficiary changes residence.
4. If the new residence will not accommodate the PWC the beneficiary is currently renting and a different base (same HCPCS code) is required will the supplier need to obtain a new detailed product description for the item that can be used in the home?
   Response: Medicare would not start a new-capped rental period in this situation. If the supplier elects to provide a different wheelchair base (different HCPCS code), a new signed and dated detailed product description is needed but a new face-to-face examination or 7-element order is not needed.
5. If a patient with a PWC moves and their new home will no longer accommodate the PWC that they have, will Medicare pay for a new PWC?
   Response: No. Medicare covers a replacement only if an item is lost, stolen, irreparably damaged, or reaches the 5 year reasonable useful lifetime. Medicare covers a different item only if there is a change in the beneficiary's medical condition.

Break in service

6. A PWC is being rented and the beneficiary goes into a hospital and nursing home for an extended stay. The supplier elects to pick up the wheelchair. When the beneficiary is ready to go back home, would there be a problem with providing a different model wheelchair within the same HCPCS code?
   Response: If the supplier chooses to deliver a different model of PWC within the same code, a new detailed product description must be obtained. A new face-to-face (FTF) examination or 7-element order is not needed.
7. If a patient who is renting a PWC goes into a hospital/nursing home for an extended time and the supplier picks up the wheelchair and the beneficiary is discharged to home, would a new capped rental period start and what documentation would be required?
   Response: Existing capped rental rules for beginning a new rental period apply to power wheelchairs. That policy states that a new capped-rental period will begin only if there has been a break in medical necessity of at least 60 days plus the days remaining in the last paid rental month. In the situation that is described, "medical necessity" would continue while the patient was in a facility. If the patient is receiving the same type of PWC (same code) on discharge that they previously had, then the rental period resumes where it left off and no additional documentation is needed (other than a new detailed product description if the make/model of the wheelchair has changed). If the patient needs a different type of PWC on discharge because of a change in their medical condition, all the requirements for a new PWC must be met (i.e., FTF exam, 7-element order, etc.).
8. If the beneficiary is renting a PWC coded K0823 prior to entering the hospital, would a new rental episode begin if, while in the hospital, they develop a Stage II decubitus ulcer over the sacrum and upon discharge require a PWC coded K0822 and a skin protection cushion, E2603?
   Response: Yes. However, following standard rules, since it is a different item, there would have to be a new face-to-face-examination (which documents the medical necessity for the new item), 7-element order, detailed product description, home assessment, etc.

Repair / Replacement

9. If, during a capped rental period, a PWC is lost, stolen, or irreparably damaged and a new PWC is provided, does a new capped rental period start?
   Response: Yes. Replacement of power wheelchairs will follow the same rules as any other rented DME item.
10. Medicare provides for the replacement of lost, stolen, or irreparably damaged items but we are concerned as to how this fits with Supplier Standard # (14), which states: "Must maintain and replace at no charge or repair directly, or through a service contract with another company, Medicare-covered items it has rented to beneficiaries. The item must function as required and intended after being repaired or replaced." Can you please clarify, as this is a significant concern for providers and beneficiaries?
    Response: The Supplier Standards address situations related to non-function or damage of an item that can be repaired or to replacement of an item due to wear and tear. Lost, stolen, or irreparably damaged items are a different category.
    The Medicare Benefit Policy Manual, Chapter 15, Section 110.2(A) states:
    "Since renters of equipment recover from the rental charge the expenses they incur in maintaining in working order the equipment they rent out, separately itemized charges for repair of rented equipment are not covered. This includes items in the frequent and substantial servicing, oxygen equipment, capped rental and inexpensive or routinely purchased payment categories which are being rented."
    
    "Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be identified. Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment." (This means that replacement due to wear and tear is possible only after the 5-year reasonable useful lifetime.)
    
    The Medicare Benefit Policy Manual, Chapter 15, Section 110.2(C) defines payment policy for items that are lost or that have been irreparably damaged by an acute incident:
    "Equipment which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage. Irreparable damage refers to a specific accident or to a natural disaster (e.g., fire, flood)."
11. Is there any situation in which a supplier can be paid for repair to a PWC during a capped period - e.g., if the supplier has information to indicate that the repair is required due to "malicious damage" or "culpable neglect" by the beneficiary?
    Response: There can be no payment for the repair of rented items under any circumstances. Reimbursement for repairs is included in the rental payments.
    
    If the supplier believes that a wheelchair repair is required because of malicious damage or culpable neglect by the beneficiary, the supplier can present the information to the DME MAC for investigation. If the DME MAC, in consultation with the CMS, agrees that the beneficiary is responsible for the damage, the supplier can charge the beneficiary.
12. How does a supplier alert the DME MAC that they believe the PWC requires a repair secondary to malicious damage or culpable neglect?
    Response: The supplier can notify the Written Inquiries Department for Jurisdiction A in writing.
13. Who is responsible for determining when a beneficiary is responsible for the damage and how will this be communicated?
    Response: As discussed in a previous question, the DME MAC will consult with CMS to make that determination. Since these are very rare situations, there is no established procedure. They will be handled on an individual basis.
14. Unique to PWCs is the fact that beneficiaries often use the products outside the home as well as inside. This is generally not done with other capped rental items (e.g., hospital beds never leave the home). If a PWC is damaged outside the home, since that is not an approved use per Medicare, will the supplier be expected to repair the chair "at no charge" during the rental period?
    Response: Yes, the supplier is responsible for the repair. Statutory coverage of DME requires that it be needed for use inside the home. However, if that requirement is met, the item may be used outside the home. Portable oxygen, nebulizers, walkers, canes, crutches, POVs, manual and power wheelchairs are among the many item, both rental and purchase, that are routinely used outside of the home setting. During the rental period, the supplier is expected to repair an item if the repair was related to damage that occurred either inside or outside the home. For purchased and rental items where the title has transferred, repairs are covered under the general repair rules.
15. How would a supplier prove the damage occurred outside the home (unless it is obvious, like sand/mud/water in the motor?
    Response: Use of a DME item outside of the home is not deemed evidence of deliberate malicious damage or culpable neglect.
16. If the beneficiary has a PWC under rental and the PWC has a service/repair issue, is it permissible to provide the beneficiary with a loaner manual wheelchair while the PWC is being repaired or is the supplier required to replace the PWC?
    Response: The supplier is required to provide a loaner item that meets the beneficiary's medical need.
17. While their rental PWC is being repaired, does monthly billing for the PWC continue?
    Response: Yes, monthly billing for the PWC would continue. There should be no separate billing and/or payment for the loaner wheelchair during the 13 month capped rental period.
18. If a replacement power wheelchair of the same HCPCS code is provided, but it is a different manufacturer, make or model than the power wheelchair listed on the detailed product description (DPD) is a new DPD required for billing the months following the replacement.
    Response: Replacement of a power mobility device (PMD) at the end of the 5 yr. useful lifetime requires a complete reassessment following the same rules as if a new initial PMD was being provided.

Miscellaneous

19. If the beneficiary weighs 478 pounds and is renting a heavy-duty PWC coded K0827 prior to a hospitalization and/or SNF stay has a significant weight loss taking them below the 300 pounds limit for standard power wheelchairs, would a new rental episode begin upon return to home, for a standard PWC coded K0825?
    Response: No. If the patient loses weight, the original wheelchair would still meet the patient's needs. If the supplier elects to provide a lower weight capacity PWC, a new capped-rental period would not begin.
20. How will the "look back" period affect the review of PWCs?
    Response: There is a general policy that coverage of items that are provided on an ongoing basis, including rented DME, is dependent on there being continued need for the item and continued use by the beneficiary. CMS and the DME MACs have not published any information regarding the look back period.
21. Will elevating leg rests (already a mandatory capped rental item) be paid at 15% in months 1-3 and 6% in months 4-13 or will they remain at a payment rate of 10% in months 1-3 and 7.5% in months 4-13?
    Response: Payment policy for accessories is not changing.
22. If payment for separately billable items at initial issue will be at the front loaded rate how will these items be distinguished as receiving a different payment methodology from the same items (other than batteries) on a PWC?
    Response: Payment policy for accessories is not changing.
23. Will a "patient requested upgrade" from a Group 2 power wheelchair (K0822 - K0831) to a Group 3 power wheelchair base (K0848 - K0855) retain the option to purchase the chair in the first month?
    Response: No, the application of upgrade provisions does not change the payment rules for any item.
24. Do PMD documentation requirements differ in any way since the elimination of the first month purchase option for beneficiaries living in a zip-coded area outside of a competitive bid area (CBA)?
    Response: The documentation requirements do not differ based upon whether the PMD is paid as a rental in a non-CBA or as a purchase in a CBA.
25. Must supplier records document ongoing use of the PMD by the beneficiary during the 13-month rental or is a physician order indicating lifetime use sufficient?
    Response: For PMDs that are provided under the rent to purchase guidelines over 13 months, it is expected that the supplier records will substantiate the beneficiary's ongoing use of the PMD for the period for which claims are submitted.
26. Is there a requirement mandating that contact with the beneficiary must be made at certain intervals to determine if a PMD meets the ongoing use requirement?
    Response: If a beneficiary discontinues use of a rental DME item, the supplier may not continue to bill Medicare for that item. Although Medicare does not have specific guidelines on how a supplier should monitor and document use, each claim submitted may be subject to review. Supplier records must clearly demonstrate ongoing monitoring and use of the rental item by the beneficiary if audited.
27. If a physician's order documents lifetime medical necessity for a PMD, must the physician's medical record indicate that the patient has been seen during the 13-month period and document that ongoing medical necessity is met?
    Response: The PMD policy does not mandate that the treating physician must formally monitor and/or recertify these devices on a scheduled basis. However, each claim may be subject to review to determine whether payment continues to be justified. Thus, some evidence must be present in the medical record demonstrating that the initial qualifying medical condition(s) continues to be present and that the need for the item continues. This may be noted intermittently throughout the course of the rental cycle.