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Take the Prior Authorization Survey

Power Mobility Devices (PMDs)

Coverage

Documentation

Reviews/Audits

  • Medical Review Results - View notifications/findings of pre/post claim reviews completed by Noridian Medical Review
  • Pre-Claim Review - View Advance Determination of Medicare Coverage (ADMC), Power Mobility Device (PMD) Prior Authorization Demonstration, and Required Prior Authorization Programs information

Prior Authorization Timelines

Policy Initial Review
Decision Timeframe
Expedited Review
Decision Timeframe
PAR Decision Valid
PMD 10 business days 2 business days six months

 

Tips

Topic Details
Advance Determination of Medicare Coverage (ADMC) Power Wheelchairs described by HCPCS K0890, K0891, and K0013 are eligible for ADMC
Billing HCPCS Code K0108 - Wheelchair Component or Accessory, Not Otherwise Specified Guidelines for appropriate billing of HCPCS Code K0108
Billing Reminder for Mounting Hardware - HCPCS E1028

Guidelines for appropriate billing of wheelchair mounting hardware are provided

Capped Rental Items 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
Discontinued Use
  • 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
Group 3 Power Wheelchair Requirements

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

Home Assessment

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

Hospital, Skilled Nursing Facility

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

KU 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
KE Append 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)
KY Append 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)
Modifier BP The beneficiary has been informed of the purchase and rental options and has elected to purchase the item. Example: K0861NUKXBP
Modifier BR The beneficiary has been informed of the purchase and rental options and has elected to rent the item. Example: K0848RRKHKXBR
Power Wheelchair Electronics Clarification

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

Repair of Rented 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
Replacement 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.
RT/LT Modifiers 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
Seat Elevation Systems as an Accessory to Power Wheelchairs E2300 (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 Assistive Technology Professional Involvement

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

Warranties 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.

 

Last Updated Feb 19 , 2024

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