With the elimination of the least costly alternative, Group 2 (K0806–K0808, K0830, K0831) and Group 4 PMD’s (K0868–K0886), are statutorily excluded from coverage and cannot be provided as an upgrade. These Group 2 and Group 4 PMD’s have added features that are not for use in the beneficiary’s home or the features are classified as non-covered. If a beneficiary qualifies for a lower level power mobility device but opts to rent or purchase one of the statutorily non-covered Group 2 or Group 4 PMD’s, there will be no reimbursement from Medicare. Suppliers submitting these codes to Medicare will receive an ANSI 96 due to the codes are statutorily non-covered.
Note: An ABN is not required to hold a beneficiary financially responsible for statutorily non-covered items.
All providers need to understand that an ANSI 96 denial means there is no appeals process. You can’t do an upgrade from a group 3 power wheelchair to a group 4 and expect any part to be paid. The group 4 base has to be billed with a GY which will get a statutorily non-covered denial (ANSI 96) so neither the upgraded base no the standard base will be covered.
This is true for group 2 POV’s and if trying to upgrade from a K0823 to a base with a seat elevator. Neither will be covered.
Any questions call Peggy Walker at 800-401-3643
Reminder This came out on March 14, 2011 as a follow up to the least costly alternative directive mandated by CMS. The local carriers can’t do anything about this rule. It has been brought to the attention of Industry / NCART/AAH/VGM/US Rehab.