For lightweight wheelchair suppliers, it is a familiar story. Because the prices of lightweight wheelchairs are higher than those of standard wheelchairs, Medicare uses stringent medical policy guidelines to determine if a beneficiary truly qualifies for a lightweight wheelchair before it will reimburse a supplier for providing one.

Obtaining reimbursement for lightweight wheelchairs provided to Medicare beneficiaries has therefore been an uphill battle over the years. The key to clean claims submission and timely payment lies in understanding the payment processes.

The first step in qualifying a Medicare beneficiary for a lightweight wheelchair is validating the beneficiary’s medical need for a wheelchair. The beneficiary’s medical condition must dictate that without the use of a wheelchair, he or she would otherwise be confined to a bed or chair.

Payment denials and downcoding for lightweight wheelchairs occur when suppliers fail to scrutinize initial diagnoses received to determine if they meet medical necessity guidelines for lightweight wheelchairs.

A lightweight wheelchair (K0003) must have supporting diagnoses that verify the Medicare beneficiary is unable to self-propel in a standard wheelchair, but can readily self-propel in a lightweight wheelchair. This requirement is normally justified by additional diagnoses that identify a medical condition that causes limited upper body strength or limited endurance, for example chronic obstructive pulmonary disease, congestive heart failure, or a neuromuscular disorder.

As the cost and sophistication of the equipment increase, so do medical necessity guidelines. Medical necessity documentation for a high-strength, lightweight wheelchair (K0004) must show not only the ability for self-propulsion, but also the need for self-propulsion while the wheelchair user is frequently engaged in activities that cannot be performed in a standard or lightweight wheelchair. In addition, the wheelchair user must spend a minimum of 2 hours per day in the chair. Logically, short-term use of a K0004 is rarely medically justified. For example, a person requiring a wheelchair during postoperative recuperation would not routinely be engaging in activities requiring this type of wheelchair.

Reimbursement for an ultralightweight wheelchair (K0005) is determined by the DME Regional Carriers (DMERCs) on an individual basis. The use of the Advance Determination of Medicare Coverage (ADMC) allows the supplier to compile all relevant medical necessity documentation to forward to the DMERC in advance. Additional information should be included that denotes or explains the Medicare beneficiary’s routine activities and substantiates that the beneficiary would be able to perform these activities while using the equipment requested. The beneficiary’s level of independence/dependence should be included with the additional documentation. The DMERC will review the submitted documentation and notify the supplier if the beneficiary meets medical necessity guidelines for the K0005. This process is advantageous to the supplier because it helps eliminate and/or reduce denials and costly payment delays.

A note of caution: It is common for the beneficiary, the beneficiary’s family, or the caregiver to request a lightweight wheelchair as a convenience to the primary caregiver. Therefore, it is important for the supplier to educate his or her staff and the beneficiary that the medical necessity justification for any item covered under Medicare is based solely on the beneficiary’s need and medical condition. The condition or strength of the primary caregiver has no bearing on the medical necessity of a lightweight wheelchair, as Medicare sees it.

But you can offer a solution. For Medicare participating providers, this is the perfect situation in which to use the upgrade provision of the Advance Beneficiary Notice. This provision allows beneficiaries to obtain the types of wheelchairs they feel they need while eliminating the financial risk to the supplier.

Next, consider documentation requirements. Although additional medical documentation may be requested through a development letter or in a postpayment audit conducted by the DMERC, routinely, the initial determination of coverage is made based on the Certificate of Medical Necessity (CMN). Therefore, before submitting a claim, review the CMN in its entirety to ensure that it is completed thoroughly and accurately, and that it meets all Medicare guidelines.

The CMN form currently used for all manual wheelchairs (including lightweight wheelchairs) is the DMERC 02.03B. When reviewing this form, suppliers should verify that:

1. They are using the correct CMN.
2. That the copy of the CMN on file is a clear copy and the form number on the top of the CMN and the Centers for Medicare and Medicaid Services (CMS) date on the bottom left of the CMN are readily visible. Recent postpayment audits have denied claims because this information was not on the CMN copy forwarded with the review request.

In addition, review the length of need and scrutinize the diagnosis codes (ICD-9) the physician entered on the CMN to verify that they are the correct diagnoses for qualifying the beneficiary for the type of wheelchair dispensed.

Keep in mind that questions number eight and nine on the manual wheelchair CMN (DMERC 02.03B) are specific to lightweight wheelchairs and the wheelchair user’s ability to self-propel. Unfortunately, the current verbiage in these two questions tends to be confusing to physicians. Therefore, you should carefully review the answers to these two questions to ensure the physician has interpreted the questions correctly and answered accordingly. Remember, if a correction is needed, you must go back to the physician as any changes to a completed CMN must be initialed and dated by the physician.

Finally, it is important that suppliers verify that a wheelchair selected for an end-user meets the coding guidelines. Fortunately, it is relatively painless to do so. A quick call to the Statistical Analysis DME Regional Carrier (SADMERC) or a visit to the SADMERC Web site will allow a supplier to determine that the SADMERC has approved the product selected for the Healthcare Common Procedure Coding System (HCPCS) code the supplier is filing.

Remember, as a supplier, you are responsible for verifying HCPCS codes applied to equipment submitted for reimbursement under Medicare. Regardless of what you are told by sales representatives, manufacturers, or other vendors, if you have any doubt that the claim is using the correct HCPCS code, the HCPCS code should be verified.

As with all high-cost items, getting lightweight wheelchairs reimbursed by Medicare can be a challenge. The key is developing a process, which includes staff and beneficiary education, and a format for establishing strong medical necessity documentation coupled with a thorough review of the documentation prior to claims submission. This will help expedite the reimbursement process and reduce costly denials and substantial payment delays.

Helen M. Farrell is a reimbursement consultant and CEO of Medical Accounting and Reimbursement Services (MARS), Chesapeake, Va. Contact MARS at (757) 410-1732.