Power Mobility Devices (PMDs) - JA DME

Power Wheelchairs described by HCPCS K0890, K0891, and K0013 are eligible for ADMC.

Guidelines for appropriate billing of HCPCS Code K0108.

Guidelines for appropriate billing of wheelchair mounting hardware are provided

Guidelines on rental and/or purchase items. Standard Power Wheelchairs (HCPCS codes K0813-K0831 and K0898) must be rented. Complex Rehabilitative Power Wheelchairs (HCPCS codes K0835-K0843 and K0848-K0864) and Wheelchair Options/Accessories Furnished for Use with a Complex Rehabilitative Power Wheelchair can be either rented or purchased.

• If a beneficiary discontinues use of a rental PMD, supplier may not continue to bill Medicare for that item
• Supplier records must clearly demonstrate ongoing monitoring and use of rental item by beneficiary, if audited

Requirements and coverage criteria for Group 3 Power Wheelchairs, HCPCS K0848-K0864, are provided.

There is no requirement for a supplier to perform a new PMD home evaluation to reassess a beneficiary's home in event that a beneficiary changes residence. Medicare will not start a new capped rental period if new residence will not accommodate PMD beneficiary is currently renting and a different base (same HCPCS code) is required. If supplier elects to provide a different wheelchair base (different HCPCS), a new WOPD is required but a new face-to-face examination (F2F) is not necessary. If a beneficiary with a PMD moves and his/her new home will no longer accommodate PMD, Medicare will not pay for a new wheelchair. Medicare covers a replacement only if an item is lost, stolen, irreparably damaged, or reaches five-year reasonable useful lifetime. Medicare covers a different item only if there is a change in beneficiary's medical condition.

If beneficiary goes into a hospital or skilled nursing facility for an extended stay, supplier may elect to pick up PMD. Upon returning home, if supplier chooses to provide a different model PMD within same HCPCS, a new WOPD must be obtained. A F2F examination is not needed in this situation. If beneficiary is receiving same type of PMD (same HCPCS) on discharge that they previously had, then rental period resumes where it left off. If beneficiary qualifies for a different type of PMD on discharge because of a change in his/her medical condition, all requirements for a new PMD must be met (i.e., F2F exam and WOPD). A new capped rental period will begin only if there has been a break in medical necessity of at least 60 days plus days remaining in last paid rental month.

The BP modifier indicates the beneficiary has been informed of the purchase and rental options and has elected to purchase the item. Example: K0861NUKXBP

The BR modifier indicates the beneficiary has been informed of the purchase and rental options and has elected to rent the item. Example: K0848RRKHKXBR

The KU modifier is used to receive the unadjusted fee schedule amount and was implemented for a variety of wheelchair accessories and seat back cushions used with K0005, E1161, E1231-E1238 and K0008.

Append the KE modifer to accessory code for contract and non-contract suppliers when beneficiary resides in a competitive bidding area (CBA) HCPCS codes K0005, K0009, K0898, E1161, E1229, E1231, E1232, E1233, E1234, E1235, E1236, E1237, E1238, and E1239).

Append the KY modifier when billing for competitively bid (Round 2 or subsequent Round) wheelchair accessories used with certain non-competitively bid wheelchair base units for beneficiaries residing in Round 2 (or subsequent Round) competitive bidding areas (CBAs)

Effective for claims with dates of service (DOS) on/after 3/1/2019, suppliers must bill each item on two separate claim lines using the RT and LT modifiers and 1 UOS on each claim line. Claim lines for HCPCS codes requiring use of the RT and LT modifiers, billed without the RT and/or LT modifiers or with the RTLT on a single claim line, will be rejected as incorrect coding. See Correct Coding - RT and LT Modifier Usage Change for more information.

DMEPOS suppliers may ensure appropriate billing of power wheelchair electronics, such as motors, controllers, harnesses and interfaces by considering clarifications provided

Prior Authorization Requests (PAR) are required for items listed on the Required Prior Authorization List. Requests for Prior Authorization of Power Mobility Devices may be submitted to review eligible PMD accessory HCPCS codes on a voluntary basis when a PAR for the required PMD base is submitted. PMDs replaced due to lost, stolen, or irreparable damage must receive a PAR decision and an expedited PAR request should be submitted for replacement PMD items.

• There is no payment for repair of rented items under any circumstances during a PMD capped rental period
• If supplier believes that a repair is required because of malicious damage or culpable neglect by beneficiary, supplier can present information to DME MAC for investigation. If DME MAC, in consultation with CMS, agrees that beneficiary is responsible for damage, supplier can charge him/her. Supplier can call the Contact Center to address this issue
• When a PMD has a service issue, supplier is required to provide a loaner item that meets beneficiary's medical needs. Monthly billing will continue while rental PMD is being repaired. There should be no separate billing and/or payment for loaner wheelchair during 13 month capped rental period

Supplier that transfers title to a capped rental item, such as a power wheelchair, to a beneficiary remains responsible for furnishing replacement equipment at no cost to the beneficiary or to the Medicare program for the 5-year reasonable useful lifetime for the equipment. In making this determination, the DME MACs may consider whether the accumulated costs of repair exceed 60 percent of the cost to replace the item.

E2298 (complex rehabilitative power wheelchair accessory, power seat elevation system, any type) is covered for Group 5 and complex rehabilitative power-driven wheelchairs. For coverage criteria review the Original Consideration for Seat Elevation Systems as an Accessory to Power Wheelchairs (Group 3) within the Mobility Assistive Equipment (MAE) (280.3) National Coverage Determination (NCD).

Supplier of a rehab PMD must employ a RESNA-certified Assistive Technology Professional who specializes in wheelchairs and who has direct, in-person involvement in wheelchair selection for patient.

Payment may be made for reasonable and necessary charges for maintenance and servicing of beneficiary-owned equipment. Reasonable and necessary charges are those made for parts and labor not otherwise covered under a manufacturers or supplier's warranty. Suppliers must maintain copies of any manufacturer or supplier warranties for equipment being repaired and furnish this documentation upon request.