The burden of proof is on the provider, so mark these reminders
by Sarah Hanna

Wheelchairs are a challenging item for providers to prove medical necessity and the viability of the claim that is billed to Medicare. The burden of proof is on the provider of the product, not the patient or the physician. I picked the K0006 heavy duty wheelchair to discuss this month because it has a higher than average denial rate. It topped the RemitDATA denial charts with an overall denial rate of 24 percent—yikes! That hurts the cash flow of a company. The specific coverage criterion that needs to be met seems simple, right? For the K0006 to be covered the patient must weigh 250 pounds or more, and this must be entered into the NTE field (narrative field) of the electronic claim through your billing software. Pretty straightforward and simple … however, as you have heard me say more than once, the devil is in the details.

Manual wheelchairs are categorized as mobility assistive equipment (MAE). In addition to meeting the weight requirement for the K0006, the patient must also meet the standards that are listed in the manual wheelchair base medical policy. When a patient is assessed “?” for MAE, the documentation submitted to support the need for the MAE must be in the clinician’s usual narrative format. The algorithm published in the National Coverage Determination, Section 280.3, and criteria located in the local medical policy manual for wheelchairs both provide clinical guidance for the coverage of MAE of the appropriate type and complexity to restore the beneficiary’s ability to participate in mobility-related activities of daily living (MRADLS) in customary locations in the home. The clinician performing the assessment must document the condition and limitations that preclude or necessitate the use of a specific MAE.

The Local Coverage Determination (LCD) for manual wheelchair bases provides suppliers with guidelines which you should use in addition to the algorithm when reviewing the chart notes to ensure that the patient meets the medical necessity for the item. The patient must meet the basic coverage rules in addition to the weight requirement for the K0006. The basic requirements are that a manual wheelchair is covered if: 1) Criteria A, B, C, D and E are met; and 2) Criterion F or G is met.

A) The beneficiary has a mobility limitation that significantly impairs his or her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming and bathing in customary locations in the home. A mobility limitation is one that:

  • Prevents the beneficiary from accomplishing an MRADL entirely, or
  • Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or
  • Prevents the beneficiary from completing an MRADL within a reasonable time frame.

B) The beneficiary’s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker.

C) The beneficiary’s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided.

D) Use of a manual wheelchair will significantly improve the beneficiary’s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home.

E) The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home.

F) The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function.

G) The beneficiary has a caregiver who is available, willing and able to provide assistance with the wheelchair.

The top denial is the 150: payer deems the information submitted does not support this level of service. One reason suppliers may receive this denial is if the equipment was a replacement and your biller did not add the RA modifier on the first month’s rental and/or add a note in the NTE field stating the specifics of the replacement. 

RemitDATA’s fourth most-common denial was 4: the procedure code is inconsistent with the modifier used or a required modifier is missing. If you receive this denial code you are probably using the wrong modifier for the rental month that Medicare has on file. This would occur if you did not check for same or similar and how many months Medicare has already paid for the K0006 upon intake. By not verifying this information, suppliers could put the wrong capped modifier on the claim.