Lightweight wheelchairs—a favorite topic of debate within the HME industry for both providers and the Durable Medical Equipment Regional Carriers (DMERCs)—are coming under greater scrutiny requiring a heavyweight approach to their provision and billing. While the Advance Beneficiary Notice (ABN) has made it easier for Medicare beneficiaries to obtain lightweight wheelchairs, it burdens them with increased financial responsibility.

For beneficiaries for whom you are trying to provide a lightweight and have it approved by Medicare, you must arm yourself with the appropriate documentation to ensure coverage and reimbursement.

While it may feel good to dispense a lightweight wheelchair to a beneficiary who qualifies only for a standard wheelchair because his or her caregiver has an easier time pushing the lightweight or loading it into the trunk of a car, you are doing yourself a financial disservice. Your difference in allowable amounts between a standard K0001 and a K0003 is approximately $420 over the cap rental period (excluding maintenance and service) using an average reimbursement of $51 for a K0001 and $86 for a K0003.

Wheelchair 101
To keep your lightweight wheelchair business a business and not a community service, start with the fundamentals. The most important piece of information you need before dispensing a Medicare-covered wheelchair is the patient’s physical condition and what the patient’s quality of life would be like without a wheelchair. Medicare’s bottom line for approving a wheelchair is if the beneficiary would be confined to a bed or a regular chair without one. If the beneficiary can ambulate (even with assistance from a person, cane, walker, etc), they will not meet Medicare’s coverage criteria and will be a candidate for a nonassigned claim (if you are nonparticipating) or an ABN outlining a lack of medical necessity.

Next you will need a Certificate of Medical Necessity (CMN) completed in full. This means you complete sections A and C of the CMN in their entirety prior to sending it to the beneficiary’s physician, no exceptions.

The physician, or someone working under the direction of the physician, then completes sections B and D of the CMN. When the CMN is returned to you, the first question, “Does the patient require the use of a wheelchair to move about his or her residence?”, must be answered “yes.” In addition, if you are providing a wheelchair accessory (elevating legrests, detachable arms, etc), the appropriate next four questions must be answered “yes” as well. Otherwise, a “no” or “does not apply” answer is OK.

Now for lightweight wheelchairs, question number eight (the sixth question on the CMN), which asks, “Is the patient able to self-propel (without being pushed) in a standard-weight manual wheelchair?”, must be answered “yes.” This question dovetails into question nine, “Is the patient able to adequately self-propel (without being pushed) in the wheelchair provided?” Obviously, this question must also be answered “yes.”

This information alone, properly transmitted to the DMERC with the correct billing codes, modifiers, and ICD-9 diagnosis codes, should get you paid according to recent regulatory changes requiring only CMNs as documentation for claim adjudication.

A Word of Caution
However, before you run out and put all your nonambulatory patients in lightweight wheelchairs armed with only CMNs completed by the physicians in the manner mentioned above, think twice. Since the implementation of this regulatory change, the number of post- and pre-payment audits has increased dramatically.

What this means is that you must have all your ducks in a row in the form of adequate documentation. In theory, CMN-only claims sound great but in reality, you are playing with a loaded gun. In the event of an audit, by either the DMERC, Benefit Integrity Unit, Office of Inspector General, or the Federal Bureau of Investigation, you will be required to provide additional documentation or face potential overpayment policies, interest, and/or fines.

To help ensure proper documentation and reimbursement, place only those beneficiaries who qualify for lightweight wheelchairs in lightweights. Copies of additional documentation, in the form of the physician’s office records, hospital records, nursing home records, home health agency records, records from other health care professionals, or test results, should be kept in each patient’s file as these documents can, and very well might, be requested in prepayment and postpayment audits.

For a lightweight wheelchair (K0003), this additional documentation should outline the base criteria for the use of any wheelchair plus a medically justifiable reason why the patient cannot self-propel a standard-weight manual chair. The documentation should also include proof that the patient can self-propel the lightweight wheelchair.

For a high-strength, lightweight wheelchair (K0004), the patient must meet the base criteria for any wheelchair and the additional criteria for a lightweight wheelchair, plus require the chair to self-propel during frequent activities that cannot be performed in a standard or lightweight chair (ie, sports or work) and/or require a seat width, depth, or height that cannot be accommodated in a standard, hemi (lower height), or lightweight wheelchair while spending at least 2 hours a day in the chair. High-strength, lightweight chairs with an estimated length of need of less than 3 months are rarely covered by the DMERCs.

For an ultralight wheelchair (K0005), the patient must meet the base criteria for any wheelchair and the additional criteria for a lightweight, plus be involved in frequent activities that cannot be performed in any other manual wheelchair.

Typical Medicare beneficiaries are rarely involved in sports, recreational activities, work, or other types of activities that would qualify them for an ultralight. Therefore, when dispensing an ultralight, be sure to have significant additional documentation outlining the patient’s abilities and limitations, both inside and outside the home, as well as the types of activities the patient is involved in. A K0005 is eligible for Advance Determination of Medicare Coverage (ADMC).

Remember, an ounce of prevention is worth a pound of cure. So, be sure to document properly, and your lightweight wheelchair claims should continue to “roll” through the DMERCs.

Jane W. Bunch, RT, is CEO of JB&CS Inc, Kennesaw, Ga. Contact JB&CS at (678) 445-1221 ext 230.