Competitively-Bid Wheelchair Accessories Furnished with Non-Competitively Bid Wheelchair Base Equipment - Clarification of the Policy

MLN Matters® Number: MM9272
Related Change Request (CR) #: CR 9272
Related CR Release Date: August 14, 2015
Effective Date: July 1, 2013
Related CR Transmittal #: R3324CP
Implementation: January 4, 2016

Provider Types Affected

This MLN Matters® Article is intended for suppliers submitting claims to Durable Medical Equipment Medicare Administrative Contractors (DME MACs) for competitively-bid wheelchair accessories furnished with non-competitively bid wheelchair base equipment provided to Medicare beneficiaries.

Provider Action Needed

The Centers for Medicare & Medicaid Services (CMS) issued Change Request (CR) 9272 as a clarification regarding CMS claims billing and processing instructions for competitively bid wheelchair accessories furnished for use with non-competitively bid wheelchair base units to beneficiaries residing in competitive bidding areas (CBAs). As a result of this clarification, you may need to resubmit certain claims that Medicare previously denied. See the Background section of this article for more detailed information on the claims you may need to resubmit.

Background

The Medicare Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) Competitive Bidding Program (CBP) was established by section 302(b)(1) of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) (Pub. L. 108-173). This publication amended section 1847 of the Social Security Act (the Act) to require the Secretary to establish and implement programs under which CBAs are established throughout the United States for contract award purposes for the furnishing of certain competitively priced items and services for which payment is made under Medicare Part B.

Currently, if a supplier submits an unassigned claim for a competitively bid accessory (identified by a Healthcare Common Procedural Coding System (HCPCS) code) that is used on a non-competitively bid base, the claim is denied because Competitive Bidding Program editing in the shared systems requires claims with CBP items to be assigned. This CR9272 adjusts that process.

With CR9272, the "Medicare Claims Processing Manual," Chapter 36, Competitive Bidding, Section 50.16 "Exception for Wheelchair Accessories Furnished with Non-Competitively Bid Wheelchair Base Equipment" is revised to state that effective for claims with dates of service on or after July 1, 2013, competitively bid wheelchair accessories are paid in accordance with standard Medicare DMEPOS payment rules, not competitive bidding rules, when furnished with non-competitively bid wheelchair base equipment (see CR 8864, Transmittal 1420, issued on August 15, 2014, for applicable HCPCS codes). (To review MLN Matters® Article 8864, you may visit https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8864.pdf on the CMS website.)

Medicare will allow an unassigned claim under the following conditions:

  • The item is a competitively bid wheelchair accessory that is used with a non-competitively bid wheelchair base; AND
  • The KY modifier is submitted with the claim.

Your DME MAC will reprocess claims that were either incorrectly paid or denied in error for dates of service between the effective date, July 1, 2013, and implementation date of CR9272 when you resubmit such claims within 6 months from the implementation of CR9272. Your DME MAC will override the timely filing edits for these resubmitted claims.

Suppliers that billed directly to the beneficiary and received payment for these claims must resubmit and give beneficiaries the applicable overpayments.

Additional Information

The official instruction, CR 9272, issued to your MAC regarding this change is available at https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R3324CP.pdf on the CMS website.

 

            Last Updated Wed, 05 Feb 2020 12:31:22 +0000