US Rehab updates ABN process for group 4 to group 3 power wheelchairs

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.

As of

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it was announced that CMS has rescinded this direction and will allow the ABN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.

The process

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

upgrade requested.

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