As suppliers, we depended on the Certificate of Medical Necessity (CMN) to protect us from postpay audits, but this was a false sense of security. We were always at risk (as many of us have learned the hard way) for postpay additional information requests. Every HME company will have to adjust to new problems now that no CMN is required.

For ALL manual wheelchairs, a postpay audit would request:

1) Copies of orders (if verbal, you need a written copy of your verbal confirmation). A dispensing order should contain: patient’s name, item description, physician/practitioner’s name, and the start date of the order (this can be written or verbal). Verbal orders can be received from someone in the ordering practitioner’s chain of command such as a social worker, discharge planner, home health nurse, or office staff member. However, you must do a confirmation of the verbal order, which includes all information received from the person calling—including all information required to allow payment for the claim.

2) A valid “written” or detailed written order, which can be a confirmation of a verbal order. A detailed written order must contain the beneficiary’s name, a detailed description of the item (along with accessories), the treating practitioner’s signature, the date the practitioner (physician, LPN, PA, or CNS) signed the order, and the start date of the order (if different from the date when the practitioner signed).

3) Beneficiary Authorization

4) Proof of delivery signed and dated by the person receiving the item. If the patient himself did not sign, than the person signing needs to put complete name, date, and relationship to patient.

5) Medical records that document the criteria for a manual wheelchair have been met.

All manual bases require documentation as to why they are needed instead of lower-level bases. This information comes from your equipment evaluation and medical records information in some instances. Remember, a lot of this information is only going to come from suppliers or therapists who are evaluating the patient, but need the physician/practitioner’s signature. The physician/practitioner does not know the equipment.

Manual Bases
• Hemi height is decided in part by height because you need a shorter seat-to-floor height for patients to place their feet on the floor to assist with propulsion, or for assisting with stand-pivot transfers.

• Lightweights are appropriate when patients are unable to self-propel in a standard weight because of conditions or surfaces in the home (carpet). This is also part of your equipment evaluation along with practitioners’ diagnoses and patients’ physical condition.

• High strength and lightweight justifications also require you to show why the patient requires this base over a lower level base. The rationale is based on activity (high activity is up in chair greater than 2 hours a day). Or perhaps the patient needs a seat width, depth, or seat-to-floor height that is NOT available in a lower level chair. Remember, you must have your equipment evaluation signed and dated by the ordering practitioner.

• Ultra lightweights (K0005s) have always been an individual consideration determined by need. To determine true need, questions must be answered such as: What is the patient in now? What are activities that they complete daily (both inside and outside the home) that cannot be done with a lower level base?

What is available on a K0005 that is NOT available on a K0004? This is specific information that is needed up front and should be the first thing you state (or the physical therapist/occupational therapist states). Do not be vague when listing needs to complete all activities of daily living (ADLs). Be specific: What does the patient do daily that requires this level of chair to remain independent? Answers may include such necessities as personal hygiene, meal preparation, readying for work, household chores, shopping, cleaning, and social interaction.

• Heavy-duty bases are specific to the weight (greater than 250 pounds) or spasticity diagnosis. The weight has to be a true weight that is documented in medical records (hospital, skilled nursing facility, doctor’s office visit). An inability to complete mobility-related ADLs (MRADLs) functionally in the home must also be documented.

• Extra-heavy-duty qualification is specific to completing MRADLs in the home along with a documented patient weight of more than 300 pounds. The need for a wheelchair, and the weight requirement, should be in medical records, which can be home health, skilled nursing facility, rehabilitation, or hospital discharge notes.

• K0009 (other wheelchair base) is a base that specifically requires additional documentation such as name, serial number, make and model of the specific base, and why a lower level chair would not meet the specific patient’s needs. This is usually for the truly bariatric patient that may exceed 500 pounds. The K0009 is a category that is deemed unique and cannot be described with a K0001 through K0007 base.

• E1161 (adult manual tilt-in-space) and E1231 through E1234 (pediatric tilts) are also specialized, and require the specific statement as to why a standard chair with a reclining back will not meet specific needs. In most instances, this requires a PT/OT evaluation along with your equipment evaluation as a detailed written order. All additional accessories that were formally covered by part C of the CMN will have to be broken out in your specific equipment recommendation forms with the physician reviewing and signing off with the date.

A lot of the manual chairs can be explained with diagnoses such as stroke or bilateral amputee. If a patient is a paraplegic, the diagnosis itself would rule out the use of a cane or walker. The diagnoses that you need to be especially careful of are the cardiopulmonary diseases or conditions, both with manual and power. These may require additional PT/OT evaluations.

Remember that mobility is specific to “functional” MRADLs and not driven by diagnosis. Explanations will need to be more specific for those patients who may be able to ambulate a few feet before becoming fatigued. DP

Peggy Walker, RN

Peggy Walker, RN, is a billing and reimbursement advisor for US Rehab/Van G. Miller Group, Waterloo, Iowa. She can be reached via e-mail: walkerp321@aol.com.