The Secret of Successful Billing

If you’ve been tuned in to government action regarding wheelchairs lately, you know that the Centers for Medicare and Medicaid Services issued a statement in December headlined: “Medicare opens National Coverage Determination (NCD) to make sure beneficiaries who need wheelchairs get them.”

So what does this mean to your business and how you bill for wheelchairs? A little history first:

On the original Certificate of Medical Necessity (CMN) that came out in 1993, question No. 4 asked: “Would the patient be bed or chair confined without the use of a wheelchair?” This CMN was for motorized and manual wheelchair bases, as well as for wheelchair options.

On the current (December 2004) wheelchair CMN for both manual and power chairs, question No. 1 asks: “Does the patient require and use a wheelchair to move around in their residence?” This in itself has opened up the coverage so that those who are physically impaired, but not completely bed- bound, can receive a mobility device to assist in functional activities.

However, contrary to popular belief, this has long been the case. I worked at Medicare for almost four years, and I never denied a wheelchair base if the patient truly needed it. I worked very closely with all four DMERC regions, and we met quarterly. I never heard one clinician say that they denied (or would deny) a wheelchair if a patient could ambulate only two feet!

If a patient needs a mobility device, Medicare will pay for it. However, there has to be documentation as to need. Providers know that if a patient ambulates into their facility, a wheelchair is not covered. Physicians, physical and occupational therapists and others, however, quite often do not understand the rules. Too often, they think that it is OK to order a scooter because their patient, after seeing a TV commercial on scooters, calls and wants one.

To get a mobility device paid, a provider just needs to use common sense and evaluate patients for what they need — not what they want. Now, this does not mean that every patient has to have the cheapest, lowest-level mobility product available. It means that evaluation of all areas of need is important.

You must evaluate patients on the following criteria:

• What are their “functional” needs — that is, their activity level and their physical abilities or endurance?
• What kind of environment do they live in?
• What are their future needs for positioning? Is their disability related to a progressive disease, for example?
• What do they need to accomplish in the chair being provided?

If you can answer these questions clearly (with the assistance of a PT/OT if available), then you can get the patient the mobility base he or she needs.

If, however, the patient insists on having the highest-end base with all the bells and whistles, then that would be considered a convenience — and that is when the upgrade option will come into effect using the Advanced Beneficiary Notice (ABN).

Be sure that when you do use an ABN, you use it correctly. Explain to patients exactly what their out-of-pocket expenses will be for the upgrade item as well as the standard item, so the patient can make an informed decision. The name, make and model of the upgrade item also must be provided on the claim, either in the narrative field on an electronic claim or in block 19 on the 1500 claim form.

When using the upgrade option, suppliers must file the CMN for the item for which the patient meets Medicare criteria — not the upgrade item. For example, if a patient meets Medicare criteria for a K0001 standard wheelchair, but wants to upgrade to a K0003 lightweight wheelchair, suppliers must submit a CMN for the K0001.

A patient who needs power because he or she cannot get around in their home without assistance should receive it, but the supplier should access the least costly alternative that meets the needs of the individual, now and in the future.

If your claim is properly coded and uses correct modifiers, if you’ve checked to make sure there is no other equipment in history, then you should be successful in getting your patient the equipment he or she needs.

Will this change with the new wheelchair coding that CMS has introduced, and the new CMN that is also expected? No one knows until the policy has been completed, but the CMN changes should be a bit more specific about functional needs.

We now know there will be many more codes than we are dealing with currently — and the greater number of codes, the more difficult it will be to apply the policy to a CMN. The CMN will need to address each level of coding. The computer sees Y – N – D (Yes, No, Does Not Apply), and it will be difficult to give accurate answers for high-end rehab chairs and accessories without multiple questions that apply to these additional codes.

Certainly, additional documentation will be needed, including an assessment by a qualified clinician or professional.

But remember: If a patient needs it, Medicare will pay for it if you bill it correctly.

Peggy Walker is a registered nurse and serves as the billing and reimbursement adviser for members of Waterloo, Iowa-based U.S. Rehab/VGM. She can be reached by members at 803/754-2090, or by e-mail at [email protected].