If you know what you're dealing with, you can avoid or reverse K0858 denials
by Sarah Hanna

This month we’re going discuss the K0858, power wheelchair, group 3 heavy duty, single power option, patient weight 301 to 450 pounds. The K0858 has an overall denial rate of 30.6 percent.

One of the main denial reasons for the K0858 is 50, not deemed a “medical necessity” by the payer. This denial code is symptomatic of the trend, which is consistent with the influx of audits. In situations where the provider responds to an audit with incomplete documentation, that provider will see the 50 denial and be faced with the appeals process.

With audits in our midst, we want to be mindful of changes that occur to Medicare policy. One occurred Nov. 30, 2012. Once a beneficiary becomes Medicare eligible and is seeking payment for a DMEPOS item obtained prior to their eligibility, all Medicare Fee-for-Service (FFS) payment and documentation rules are applicable to the DMEPOS item on the date of service for the item.

Purchased Items (Including Supplies):If, at the time of transition to Medicare, the beneficiary owns a DMEPOS item that can be purchased under the Medicare Program, Medicare can pay for reasonable and necessary supplies and repairs. At the time of replacement of that entire item, Medicare treats the claim as a new initial claim. Therefore, all coverage and documentation requirements must be met to justify reimbursement. For durable medical equipment, only certain items can be paid for on a purchase basis under the Medicare Program. Medicare payment can only be made for necessary supplies and repairs of beneficiary-owned equipment that Medicare can purchase, which includes items classified under the program as inexpensive or routinely purchased items, complex rehabilitative power wheelchairs or customized items uniquely constructed or substantially modified for a specific patient. This applies in all situations.

Rental Items:For rental items, Medicare does not automatically assume payment for the item. Rental coverage by Medicare is treated as a new initial claim, not as a replacement. Therefore, all coverage and documentation requirements must be met to justify reimbursement. The disposition of the original item rests with the original payer, not Medicare. In addition to meeting Medicare’s coverage requirements, Medicare requires that the Medicare-billed equipment be new or refurbished at the start of an initial rental. All rented equipment must remain in good working order for the entire five-year reasonable useful lifetime of the equipment. If the equipment doesn’t last that long the supplier must replace the equipment at no charge to Medicare or the beneficiary. When billing for the Medicare initial date of service, standard documentation requirements, including proof of delivery, apply.

According to Medicare’s Listserve notifying suppliers of this change, results from recent reviews uncovered several misconceptions about the documentation requirements for claims for a beneficiary who previously received equipment from a prior insurer. They include: 1) Changes to the proof of delivery (POD) are not annotated. This is incorrect. Any changes or corrections on the POD must show that the beneficiary or caregiver has signed or initialed, and dated the changed document, and 2) The proof of delivery provided is from the delivery with the previous payer which is not appropriate to demonstrate proof of delivery for a new Medicare item. For items that require a CMN, the “Delivery Date/Date of Service” on the claim must not precede the “Initial Date” on the CMN or DME Information Form (DIF) or the start date on the written order. Suppliers must follow the standard documentation language regarding the elements required for proof of delivery based on the method of delivery. Source: Based on analysis of Medicare claims processed for RemitDATA customers during the first quarter of 2012. Contact RemitDATA by phone at 866-885-2974 or go online to the company’s website at www.remitdata.com.