Article Detail - JD DME

Original Effective Date: 03/15/2002
Revision Effective Date: 11/01/2013

Data analysis on items coded K0108 revealed many claim denials, frequent requests for additional information, and multiple submissions of claims for payment. Several patterns of billing errors were identified involving large numbers of suppliers across all Region D states. Review of the most common errors may result in more accurate claim filing.

The local medical review policy (LMRP) entitled Wheelchair Options and Accessories (DMERC Region D Supplier Manual , Ch. 9, pgs. 1-6) details the coverage and payment criteria which must be met for any accessory to be considered for coverage. Those requirements are:

• The patient has a wheelchair that meets Medicare coverage criteria; and
• The patient's condition is such that without the use of a wheelchair, he would be bed or chair confined (an individual may qualify for a wheelchair and still be considered bed confined); and
• The options/accessories are necessary for the patient to perform one or more of the following activities:
  • function in the home;
  • perform instrumental activities of daily living.

An option/accessory that is beneficial primarily in allowing the patient to perform leisure or recreational activities is noncovered.

Wheelchair options/accessories that are individually coded have defined criteria for coverage. Miscellaneous options, accessories, or replacement parts for wheelchairs that do not have a specific HCPCS code are to be coded K0108. K0108 items do not have specific coverage criteria.

Documentation must indicate that the item meets all the criteria above, as well as outline the specific medically necessary purpose for which this piece of equipment is intended.

If multiple miscellaneous accessories are provided, each should be billed on a separate claim line using code K0108. When billing more than one line item with code K0108, suppliers must ensure that the additional information can be matched to the appropriate line item on the claim. It is also helpful to reference the line item to the submitted charge. If code K0108 is billed for nonstandard seat dimensions, the submitted charge should represent the incremental additional charge not included in other submitted codes.

A claim for code K0108 must include a narrative description of the item, the brand name, model name/number of the item, and a statement defining the medical necessity of the item for the particular patient. If it is a customized option/accessory, the statement must clearly describe what was customized. If a formal wheelchair evaluation was performed, it would be helpful to include this information. Other information that is helpful in assisting the medical review staff to determine coverage includes:

• information on the patient's diagnosis
• the patient's abilities and limitations as they relate to the equipment (e.g., degree of independence or dependence, frequency and nature of the activities the patient performs, etc.)
• duration of the condition
• expected prognosis
• past experience using similar equipment
• any other information that would enable a claim approver to understand the purpose or function of a K0108 item

Most importantly, it is necessary for suppliers to submit all the required information for K0108 items at the same time. Claims received with partial information will be paid or denied based on submitted records. That data is then filed and not available for review with subsequent claims. If a claim is resubmitted with additional information, copies of any previously supplied documents should be included as well. Complete documentation will allow a speedy and accurate determination.

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