January 1, 2011 Medicare came out
with the Least Costly Alternative directions relating to CMS’s mandate that the
DMEMACS are to no longer automatically down code any items. Because of the way
the narrative was written in the LCD, this has caused a huge issue with certain
products of which the supplier community was not even aware.
February 4, 2011, items could not receive the auto down code. One specific item
was the fully electric hospital bed. If this was billed on or after February 4,
DME providers would receive a denial as non-covered and would be allowed to
rebill as a “free” upgrade option.
However, the Group 4 power wheelchairs
that were supposed to be down coded had a different narrative description. The
denial for these would be a statutorily non-covered ANSI 96 denial, which has no
appeal rights. Since this would happen, the standard base that met the patients’
needs would also deny as ANSI 96.
Once the industry became aware, it
informed CMS that this would basically remove any patient choice from the
On April 27, 2011 at the Jurisdiction C Council meeting,
it was announced that CMS has rescinded this direction and will allow the ABN
process to become effective again on June 1, 2011.
will remain the same but the wording will change from statutorily non-covered to
not reasonable and necessary. This will allow a medical necessity denial for the
upgraded item and payment to be made (if all documentation is there and the item
is billed correctly) for the item the patient meets criteria for.
rule for the upgrade from a K0823 to a chair with a seat elevator K0831 will
remain and there will be no way to allow for an upgrade with these codes.
However, if a manufacturer has a base that is coded as a K0823 that happens to
have a seat elevator, it is acceptable to do. No ABN for the seat elevator is
required, and the item is not required to be billed.
The issue with the
K0822 rehab seat with an essential cushion is still under the radar for US Rehab
and we will continue to work to get this corrected.
To bill for an
upgrade for the Group 4 versus the Group 3
on first line
K0861NUBPKX99 on second line with narrative NUBPKHKXGK