From transport chairs and manual wheelchairs to scooters and power chairs, wheelchairs can represent a significant revenue stream when billed and reimbursed properly and a significant cash drain when not. Consequently, it is a good idea for HME dealers to regularly review reimbursement methods for all types of wheelchairs.

The best-example payor when reviewing any set of reimbursement procedures is, of course, Medicare because it will usually make HME dealers jump through the most hoops to get paid. If you understand Medicare reimbursement, most other payors will seem like a walk in the park.

Start by identifying the general type of patient Medicare is looking for to qualify a wheelchair. The underlying criteria, in Medicare’s eyes, for placing someone in a wheelchair are that, if the person was not in the wheelchair, he or she would be confined to a bed, couch, or other piece of furniture in the home. If a patient is at all capable of ambulation (even with assistance from a person, a walker, or a cane), that person does not meet Medicare’s guideline for coverage. The only exception is if the person is just mobile enough to move from a bed to a bedside chair or commode because Medicare does not consider limited transfer mobility as ambulation.

Remember, Medicare will always look for the least costly alternative to accommodate the patient. If it believes that the patient can be accommodated in a standard wheelchair, it will prefer to reimburse for the standard chair rather than a lightweight or ultralight wheelchair.

The Key Three
Medicare covers three basic types of wheelchairs—transport, manual, and power—as well as various wheelchair accessories.

Transport Chairs: While usually not considered true wheelchairs because they cannot be self-propelled, the transport chairs (also known as roll-about chairs) are covered by Medicare when prescribed by a patient’s physician in lieu of a regular wheelchair.

Medicare-covered transport chairs are those that have caster wheels of at least 5 inches in diameter and that were specifically designed to meet the needs of ill, injured, or otherwise impaired individuals.

Because Medicare considers transport chairs as wheelchair substitutes, billing one simultaneously with any manual or power chair is prohibited. However, because Medicare also does not consider them true wheelchairs, a certificate of medical necessity (CMN) is not required to file a transport chair claim.

New this year is that the billing code for a transport chair has changed to E1038 for dates of service after January 1, 2003.

Manual Wheelchairs: These are the most commonly dispensed types of wheelchairs and are covered by Medicare when combined with a properly completed CMN (DMERC #02.03B) and any required additional documentation.

There is a specific “pecking order” of types of manual wheelchairs and each has slightly different qualifying criteria. They are often referred to by their Healthcare Common Procedure Coding System (HCPCS) code, which can cause confusion for those less familiar with wheelchair billing. To clarify, they are:

K0001: A standard weight manual wheelchair. To qualify for a K0001, a patient must meet Medicare’s minimum wheelchair guidelines and have a corresponding qualifying diagnosis.

K0002: A hemi wheelchair. K0002s have a seat height lower than that of a standard manual wheelchair to accommodate short patients who still want to propel with their feet.

K0003: A lightweight wheelchair, so called because these wheelchairs weigh less than 36 pounds to accommodate patients who are incapable of self-propelling a standard wheelchair but who are capable of self-propelling a lightweight wheelchair.

K0004: A high-strength lightweight wheelchair. K0004s have a seat width, depth, or height that cannot be accommodated in a standard lightweight wheelchair. However, to qualify for a K0004, a patient must spend at least 2 hours per day in the wheelchair.

K0005: An ultralight wheelchair, so called because it weighs less than 30 pounds. Coverage for these wheelchairs is usually decided on an individual basis.

K0006: A heavy-duty wheelchair. Medicare covers K0006s for patients weighing 251 to 300 pounds.

K0007: An extra heavy-duty wheelchair. K0007s are covered for patients weighing 301 pounds or more.

K0009: A manual wheelchair base other than those included in codes K0001 through K0008. To be covered, a K0009 claim must include medical necessity for the wheelchair base and why another K0001 through K0007 base is unacceptable.

Advance Determination of Medicare Coverage (ADMC), formerly known as prior authorization, is available for K0005 and K0009 manual wheelchair bases. ADMC allows an HME supplier to find out if Medicare is going to cover a particular wheelchair for a patient’s specific condition and circumstances before the claim is filed.

However, be sure to send the ADMC request to the correct DMERC address. If it is sent to the regular claim submission address, it may not get processed.

Also remember that all manual wheelchair bases—except the K0005 and K0009—are capped rental items. Therefore, at the time of intake, you must ask patients if they have ever received a wheelchair from another provider so you do not get caught supplying an expensive wheelchair to a patient who has partially or totally capped out another wheelchair with a different supplier.

Power Wheelchairs: An ever-increasing number of dealers are stocking and supplying motorized “power” wheelchairs. With this increase in popularity at both the retail and consumer level, power wheelchair manufacturers have gone as far as running national television ads to boost demand. But be careful. A good rule of thumb related to any medical device reimbursed through federal and state programs is that if you see an item on television, Medicare and Medicaid sees it, too, and audits of these claims will not be far behind.

While most dealers provide these “big ticket” items legitimately, there is a small number of dealers that provide these wheelchairs wherever they can, even when a power wheelchair is not strictly necessary. It is these companies that cause us all to have to jump through additional hoops to get paid. Therefore, adopt a simple common sense approach to supplying and billing these chairs. It can save you, and possibly the HME industry, some future operational and financial nightmares.

To qualify any patient for a power wheelchair, two underlying factors must be present. The first is the same as the reason for putting a patient in a manual wheelchair—without the power wheelchair, the patient would otherwise be confined to a bed or another piece of furniture within the home. The second underlying qualification is that the patient must be completely incapable of operating any type of manual wheelchair. This second qualification manifests itself as a severe weakness of the upper extremities due to a neurological, muscular, or cardiopulmonary disease or condition preventing the patient from self-propelling a manual wheelchair.

Since last year, Medicare reimbursement is based solely on the merits of the CMN; however, audit-proof providers have documentation within their patient files outlining patients’ medical conditions and the medical reasons why the patients are qualified for power chairs. The file should also include documentation of the patient’s physical and mental capacity for safely operating the power wheelchair.

This medical documentation can take many forms but the two most common are documentation from the patient’s physician or a written evaluation by a physical therapist. This information need not be provided with the original claim to Medicare, but auditors will definitely request it in any type of postpayment review.

Like manual wheelchairs, power wheelchairs are usually referred to by their HCPCS codes. These are:

• K0010: Standard-weight motorized wheelchair.
• K0011: Standard-weight motorized wheelchair with programmable speed controls.
• K0012: Lightweight motorized wheelchair.
• K0014: Other motorized wheelchair.

Wheelchair reimbursement is a complicated area and this is really only the tip of the iceberg. However, reviewing the basics of wheelchair billing is prudent for all HME providers who seek to avoid trouble with postpayment audits on their wheelchair claims.

Bruce Brothis is president and CEO of Centralized Billing & Intake Ltd in Parker, Colo. He has more than 22 years of HME industry experience and speaks and consults for HME companies across the nation. Contact him at (800) 396-9910 ext 13.