With the elimination of the prior authorization program by the Durable Medical Equipment Regional Carriers (DMERCs) on September 1, 2001, HME providers must now rely on their knowledge and understanding of medical policies and coverage guidelines when making the assignment decision. Previously, many providers used the prior authorization program to determine if a patient met the medical necessity requirements for high-ticket items, such as seat lift chairs. Now adrift, providers are faced with a dilemma: Should I accept assignment on seat lift chair mechanisms?

—Jane W. Bunch, CEO, Jane’s billing and Consulting Inc, Marietta,Ga

Making the assignment decision can be less painful (as well as more cost-effective) if you take time to review both the documentation requirements and the medical necessity guidelines. Although seat lift mechanisms (E0627) require a written order prior to delivery (WOPD), you must obtain and review the completed Certificate of Medical Necessity (CMN) (DMERC 07.02A) before agreeing to accept assignment on the claim.

To determine if a patient meets the medical necessity criteria for a seat lift mechanism, verify that the patient meets the specific guidelines established by the DMERCs. This means the patient must have severe arthritis of the hip or knee or have a severe neuromuscular disease. You can easily determine this by reviewing questions No. 1 and No. 2 on the CMN.

When reviewing the physician response to these two questions, it is critical that you also review the ICD-9 (diagnosis code) the physician entered on the CMN to determine that the diagnosis matches the answer to questions 1 and 2. Although the most common forms of arthritis seen on CMNs are osteoarthritis and rheumatoid arthritis, keep in mind that there are more than 100 recognized forms of arthritis, including scleroderma and lupus, that may qualify the patient.

Qualifying neuromuscular diseases may include, but are not limited to, multiple sclerosis and myasthenia gravis.

Get the physician on your side
A review of the additional requirements for seat lift mechanisms makes clear the importance of communicating with and educating the patient’s physician on Medicare policies and guidelines. Often, during a post-payment review, the DMERC may determine that its requirements were not met because there is no evidence of the requirements in the physician’s patient file.

Make sure that the physician knows that to get Medicare coverage, the seat lift mechanism must be a part of his or her overall plan of care and treatment of the patient and must be prescribed to improve, arrest, or retard deterioration of the condition the physician is treating. Educate and encourage the physician to document in the patient’s chart the reason he or she prescribed the seat lift mechanism and the goals or benefits the physician hopes to achieve through its use.

Medicare also requires that the patient be completely incapable of standing up from a regular armchair or any chair in their home (CMN question No. 2). Documentation that notes a patient has difficulty or is unable to get up from a chair (particularly a low chair) will not meet Medicare’s requirements for a needed seat lift mechanism. Since the majority of ambulatory patients are able to get up from a chair if the seat height is appropriate and the chair has arms, this constitutes a very restrictive requirement. Again you must educate the physician and request that documentation of the patient’s limitations be added to his or her chart.

Once the patient is standing, Medicare requires that the patient be able to ambulate (CMN question No. 4). In addition to asking the physician to document the patient’s ability to ambulate upon standing in the patient’s chart, verify that the patient has not previously, or does not currently, use a manual wheelchair, power wheelchair, or power operated vehicle (POV) for their mobility needs. If the patient has previously used one of these products, obtain additional documentation denoting the improvement in the patient’s condition that now allows ambulation.

Finally, documentation in the patient’s medical records must prove other treatments to enable the patient to transfer from a chair to a standing position were tried and failed (CMN question No. 5). Verify with the physician that this requirement was met and documentation in the patient’s medical records shows past orders for physical therapy and pain and inflammation relief medications, such as nonsteroidal anti-inflammatory drugs (NSAIDs) and/or corticosteroids, were prescribed and proved ineffective.

Dealing with unqualified patients
After reviewing the CMN and determining if the required additional documentation is readily available in the patient’s medical records, you should have the necessary information to make the assignment decision. If you determine that the patient does not qualify for the seat lift mechanism, but the patient still wishes to purchase the item and requests the claim be filed to the appropriate DMERC, obtain a signed and dated Advance Beneficiary Notice (ABN). The ABN must contain a detailed description of the item and the reason you feel the patient does not qualify for Medicare reimbursement for it. Remember to add a “GA” modifier after the Healthcare Common Procedure Coding System (HCPCS) code when filing the claim, to notify the DMERC that the ABN is on file.

Also keep in mind that only the seat lift mechanism is a Medicare-covered item. For purposes of this article, I only referenced the E0627—a seat lift mechanism incorporated into a combination lift-chair mechanism. When filing a claim for an E0627, file the chair portion of the product as A9270, a noncovered item or service. You may charge and collect the amount for the chair directly from the patient, as it is a noncovered item.

Hopefully, you now better understand the steps required to qualify a patient for a seat lift mechanism before the assignment decision is made. Certainly, nonparticipating providers can view seat lift chairs as cash-sale only items and not accept assignment. They are still required, however, to complete and file a claim to the DMERC at the beneficiary’s request if the proper documentation has been obtained.

Seat lift chair sales continue to show strong growth as evidenced by expanding competition and availability, as well as the manufacturers’ additions of popular luxury features, such as heat and massage. Therefore, the medical necessity and documentation requirements should not discourage you from entering or staying in the seat lift chair market. For providers willing to understand the documentation requirements and medical necessity guidelines for seat lift chair mechanisms, the sale of seat lift chairs can greatly enhance cash flow and improve their bottom lines.

Jane W. Bunch is CEO of Jane’s Billing and Consulting Inc, Marietta, Ga. Contact JB&C Inc at (678) 445-1221.