How should you prepare for the 64 new PWC codes that go into effect on October 1?  

We all now know there will be 64 new codes (61 plus three miscellaneous codes) for power wheelchairs (PWCs) and scooters, but what does this really mean? These codes go into effect October 1, 2006—K0800 through K0808 and K0812 for scooters, and K0813-K0800 for PWCs.

The specifics for these codes are incomplete as of July 2006, as far as what is included in the standard package descriptor for each code. The DME Medical Directors have a lot of work that will have to be completed in a short amount of time if they are to be ready for October 1. They would hope to have the coverage criteria ready at the same time as the codes become effective, but that may not be possible with the 45-day comment period that is required. This may delay the codes.

Manufacturers will have to have their products retested at an independent testing facility to evaluate for changes and than submit these to SADMERC for the new coding verification. The timing for this alone is highly unpredictable. Make sure you keep in contact with your manufacturers so you know where they are in the process and what chairs they already have coded. All products will have to be coded to be covered.

Documentation changes have been updated as of July 12 as well. We now have 120 days for delivery of the product from date of face to face evaluation. The supplier must complete an attestation statement of no financial involvement with the clinician completing the evaluation (PT/OT), and the detailed written order must contain the pricing information (your charge and Medicare allowable) as well as a complete description of the item being provided.

The time from when the physician completes the information to when the supplier receives it is 45 days, and the information requires a date stamp OR equivalent to prove this rule is being followed. These rules will be applied to those claims received by the carrier on or after August 10, 2006 (except if the 45 days was effective June 5).  

The big problem in the past was the wide range of items lumped into one code. Therefore, the additional codes will be good in some ways. Of course, there will be those that will seek the highest reimbursement codes for every patient regardless of need. The structure of the codes will have (supposedly) specific criteria for the level of functional needs for a specific range of patients. This means down codes will be possible.

We as suppliers must be even more aware of the proper use of advance beneficiary notices (ABNs) for upgrades and possible medical necessity denials. As we are aware, the use of ABNs is increasing, but many still do not understand the value of using these appropriately. They can be used for free upgrades, upgrades within the same HCPCs code, as well as beneficiary choice upgrades.

The tightening of the criteria and specific documentation requirements will mean suppliers will have to increase educational efforts to referral sources, ordering practitioners, and clinical resources. Since the exact information required is actually detailed and specific, suppliers must make sure this documentation is “in our files” before submitting a claim. Cardiopulmonary diseases and condition diagnoses could even trigger a request for additional laboratory tests such as pulmonary function tests, ECGs, and stress tests.

For now, you need to keep up with what is going on within your DME Medicare Administrative Contractor and closely watch any updates that come from the Listserv announcements. US Rehab/VGM has an open discussion board that is updated regularly with any and all new information as we receive it. As always, make sure you document, document, document.

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