Medial Policy updates effective 10/01/2013

Medial Policy updates effective 10/01/2013

Manual Wheelchairs

Added code K0008 / will be ADMC eligible / coverage and indications:

1.    A custom manual wheelchair base (K0008) is covered if, in addition to the general coverage criteria above, the specific configuration required to address the beneficiary’s physical and/or functional deficits cannot be met using one of the standard manual wheelchair bases plus an appropriate combination of wheelchair seating systems, cushions, options or accessories (prefabricated or custom fabricated), such that the individual construction of a unique individual manual wheelchair base is required.

If K0008 is used to describe a prefabricated manual wheelchair base, even one that has been modified in any fashion, the claim will be denied for incorrect coding. Refer to the CODING GUIDELINES section of the related Policy Article for additional information about correct coding of K0008. 

A custom manual wheelchair is not reasonable and necessary if the expected duration of need is less than three months (e.g., post-operative recovery).

2.       A custom manual wheelchair base (K0008) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of the beneficiary’s treating physician. The beneficiary’s needs cannot be accommodated by any other existing manual wheelchair and accessories, including customized seating arrangements. See 42 CFR Section 414.224, and Internet-Only Manual, Publication 100-04, Medicare Claims Processing Manual, Chapter 20, Section 30.3 for more information on customized DME.    custom manual wheelchairs must also have a lifetime warranty on side frames and crossbraces.

3.       A transport chair (E1037, E1038 or E1039) is covered as an alternative to a standard manual wheelchair (K0001) and all criteria for a wheelchair is met

4.       K0108 removed as a billing method for w/c modifications

Supplier records documenting beneficiary confirmation of continued use of a rental item /

Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in policy.

Power Mobility   LCD updates  

Added  K0013 / ADMC eligible/ not subject to PDAC code verification

A custom motorized/power wheelchair base (K0013) will be covered if:

1.     The beneficiary meets the general coverage criteria for a power wheelchair; and

2.     The specific configurational needs of the beneficiary are not able to be met using wheelchair cushions, or options or accessories (prefabricated or custom fabricated), which may be added to another power wheelchair base. 

    If coverage criterion 1 for K0013 is not met, the claim will be denied as not reasonable and necessary.

    If coverage criterion 2 for K0013 is not met, the claim will be denied for incorrect coding (see related Policy Article for additional information).

    A custom motorized/power wheelchair base is not reasonable and necessary if the expected duration of need for the chair is less than three months (e.g., post-operative recovery).

3.     A custom motorized/power wheelchair base (K0013) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of the beneficiary’s treating physician. The beneficiary’s needs must not be able to be accommodated by any other existing PMD and accessories, including customized seating arrangements. 

·         Rental pwcs – continued used documentation **** Supplier records documenting beneficiary confirmation of continued use of a rental item ****   Timely documentation is defined as a record in the preceding 12 months unless otherwise specified elsewhere in this policy.