The term “lightweight wheelchair” means different things to different people. A man (with no knowledge) may want/need a lightweight wheelchair to merely push his wife from point A to point B—and nothing more. This could be something as simple as a transporter chair (E1038). At the other end of the spectrum is a patient who looks at a lightweight wheelchair as “extremely” light and more maneuverable, such as a K0005 (ultra lightweight).

When Medicare officials see the word lightweight, they expect a “lightweight wheelchair base” (K0003). Some providers, depending on experience, consider a “lightweight wheelchair” to have a K0004 (high-strength, lightweight) base.

Clinicians (therapists and nurses) may say, “The patient is able to self-propel using a standard wheelchair at the facility,” which may mean the “standard” wheelchair at their particular facility is a K0003, and not really a Medicare standard base at all (K0001). This would cause a problem with a postpay review on the K0004 base. And lately, the most-reviewed “lightweight” in Region A is the K0004.

Back to the Base
Let’s say you have a physician’s order for a wheelchair, someone qualified to evaluate the patient, and a patient who needs a mobility device because he can not ambulate functionally and independently. For our purposes, functional ambulation means the patient needs a mobility device to complete tasks of daily living in the home.

The first base to look at is the E1038, which was formally in the rollabout chair code of E1031. The E1031 basically requires a prescription from the physician that states the patient needs this “in lieu of” (instead of) a standard wheelchair base.
1) The E1031 does not require a CMN.
2) It is a capped rental.
3) The E1031 stipulates that the patient requires a wheelchair to move around in his residence.

If the patient is unable to self-propel a standard manual wheelchair (K0001), then we look at the lighter weight wheelchairs. (We will skip the K0002 [hemi-height] here.)

The lightweight wheelchair (K0003) requires:
1) a prescription from the physician;
2) that the patient needs a wheelchair to move around in his residence;
3) that the patient can and does self-propel himself in the base provided; and
4) a completed CMN.

If for some documented reason the patient needs a K0004, the following conditions will need to be met:
1) a prescription from the physician;
2) a CMN;
3) proof that the patient needs a wheelchair to move around in his residence;
4) some type of documentation as to why a K0003 or lower level chair will not meet his needs;
5) the K0004 may have to be used for the individual that is a lot more active or has a need for some item that is available on a K0004 base (that is not available on a lower level base); and
6) the K0004 is the only base code that states that patients must require it for longer than 3 months and be up in the chair for at least 2 hours per day.

Documentation for this base can be an equipment evaluation that states the need for an adjustable back height that is not available in a lower level base or the activity level of the patient. This documentation would be looked at if it were part of the wheelchair evaluation/specification information. The patient’s measurements would be significant in several cases. The patient may not be able to self-propel but needs this base because of size.

Ultra Lightweight (K0005)
The ultra lightweight base (K0005) is significant in its detailed needs. A complete identification of all daily living tasks is most important in this case (inside and outside the home). The K0005 base (ultra lightweight) needs:
1) a prescription from the physician;
2) a CMN;
3) additional documentation;
4) a list of ADLs completed in the chair both inside
and outside the home;
5) proof the patient is independent in propulsion; and
6) documentation that there is something available on the K0005 that is not available on a K0004.

All DMERCs expect this base to be for more active individuals, which of course is not always the case when you need to do a lot of positioning on patients that are elderly and have decreased strength. The only other option on many would be to go to power, which many patients do not want to do.

Upgrades and More
To bill for a “free” upgrade, use the standard item that the patient meets criteria for on the CMN (and on the 1500 form [or electronic filing]). Use the GL modifier indicating you are giving the patient an item that is not the one you are billing for. In the HAO record (narrative field) of electronic billing, state exactly what was provided (an ABC upgrade was given because this is what I chose to maintain in stock). This can be done with any level of base, and you can choose what base you decide to keep in stock. Your billing code would be whatever you provided with the GL modifier added.

Upgrade with an advance beneficiary notice (ABN) for something the patient “wants” instead of “needs.” For example, if a patient meets criteria for a standard base wheelchair but wants a K0004, you will need:
1) an order for the standard base;
2) a CMN for the standard base;
3) an ABN signed by the patient or authorized individual; and
4) an ABN that clearly explains the out-of-pocket expense for the standard item, as well as the upgraded item. For example, if you get the standard item and you have no secondary, your out-of-pocket expense will be 20% of the allowed amount each month. Your out-of-pocket expense for the upgraded item would be 20% of the allowed amount of the upgraded item, plus the difference in the company’s charge for the upgraded item and Medicare’s allowable of the nonupgraded item.

You would bill:
1) the first line of 1500 form as K0004RRKHGA; and
2) the second line of 1500 form as K0001RRLHGK.

You would collect up front:
1) any co-payments (if no secondary insurance) and any unmet deductibles; and
2) the difference between your charge for the upgraded item and the Medicare allowable of the standard item.

Remember to explain that this will change in the fourth month.

It is important to make sure your customer service, sales, and billing staff members fully comprehend this process. An audit on K0004s could also include recoupment of accessories as well as the base.

Peggy Walker, RN, is a billing and reimbursement advisor to members of US Rehab and Van G. Miller & Associates, Waterloo, Iowa. She can be reached via email: walkerp321@aol.com.