K0007 Extra Heavy Duty Wheelchair

Manual wheelchairs are one of the many products that require a lot of work and documentation to receive payment from Medicare. Once the documentation has been reviewed and the claim has been sent, it is deflating to receive a denial. But with an overall 20.3 percent denial rate, providers get a lot of them for K0007 wheelchairs.

One of the top denial reason codes for the K0007 is the CO176, which states “the prescription is not current.” Why do you get this denial, and how do you work it and get the extra heavy duty wheelchair paid?

When the initial date of service for a piece of capped rental equipment is billed to Medicare, a “dummy” CMN is created in the Common Working File (CWF) with a length of need of 13 months. This is done even though manual wheelchairs do not require a CMN. Medicare utilizes the dummy CMN to track how many months it should pay for that item.

There are instances when a patient has a break in service (was admitted to a hospital or skilled nursing facility) or has a break in medical need (no longer needs that piece of equipment for a medical reason). If the patient requires that equipment again, it will most likely result in billing for rental months that have now fallen outside of that first 13-month allowance set up in the dummy CMN. This results in a CO176 denial. The CO176 is traditionally a CMN denial, but because the CWF shows that the dummy CMN has expired, a claim for a piece of equipment that does not require an actual CMN may receive the same denial.

In the case of a break in service when the patient was admitted to a facility but still needed the equipment for the same medical reason, your only option on a CO176 denial is to request that Medicare extend the capped rental period to include the remaining rentals up to 13 total months. This can be done through a written reopening request specifically asking that the capped rental period be extended.

If there was a break in medical need, you may have the option to restart the capped rental period. This would mean a full 13 months of payment regardless of the rental months paid during the previous rental period. To do this, you have to show that the medical reason the patient needs the equipment now is different than the medical reason he or she needed it during the first rental period. This information should be submitted in written form to the reopening department requesting that the capped rental period be restarted.

You might also receive this denial if the patient rented the wheelchair from a previous supplier and, for one reason or another, switched to your company. In this circumstance, you will not be able to go to the reopening department and request an extension. You will only be paid for the months that were left in the cap after the patient left the previous supplier.

Based on analysis of 8,945,016 claims processed for RemitDATA customers during the fourth quarter of 2009. Source: RemitDATA, 866/885-2974, www.remitdata.com

Read more Working Down Denials columns.

Sarah Hanna is a reimbursement consultant and vice president of ECS Billing & Consulting, Tiffin, Ohio, and specializes in proper billing protocols, Medicare coverage guidelines and billing office procedures. You can reach her at 419/448-5332 or [email protected].