By: Dan Fedor, U.S. Rehab
Many wheelchair competitively bid accessories are used both on competitively bid bases and complex rehab bases. While some of these accessories vary in construction (quality and cost) they have the same HCPCS code regardless of what type of base it is being used on. When these codes were bid through the competitive bidding program Medicare acknowledged that the competitive bid rate (AKA - single payment amount (SPA)) is not appropriate when the bid accessories are used on a complex rehab base, therefore, they established pricing modifiers (KY and KE) that when used appropriately would change the allowable from the SPA to the fee schedule (the fee schedule is higher).
Unfortunately, this did not work correctly and the bid accessories being used on a complex rehab base paid at the SPA. Medicare acknowledge that they were not paying these codes correctly and a change request (CR 8864) was issued on Aug 15, 2014 with an implementation date of Jan 5, 2015 to correct their system error. Providers were informed that claims submitted on or after Jan 5, 2015 would now be paid at the correct amount and that previously incorrect payments would be fixed by either an automatic mass adjustment or through a reopening request.
As of March 2015 it appears as if this "fix" is not working as stated in the CR. We are hearing (and seeing) from some members that they are still being paid at the SPA for bid accessories on complex rehab bases. We urge our members to review allowed amounts to determine if you are being shortchanged.
The purpose of this article is to ensure our members are aware of this issue and keep track of these incorrect payments. When something like this happens Medicare always asks for examples so we are asking that you review your reimbursement amount for these claims and, if paid incorrectly, share some examples (minus patient info for privacy) with us to share with the DME MAC, CMS and congressional representatives. As VGM / US Rehab members we want to ensure you are NOT getting shortchanged and if you are, we will work to ensure you receive the accurate reimbursement for your services.
On another note the DME MACs have stated that bid items (as a repair / replacement) used with complex rehab patient previously owned bases (not new) should pay at the SPA and not the fee schedule. This is incorrect as the CR doesn't differentiate between using the bid item on a new wheelchair or a previously owned wheelchair. The CR simply states that when the bid accessory is BILLED FOR USE WITH a complex rehab base it should pay at the fee schedule. This issues is being raised with CMS as well.
MLN Matters® Change Request 8864
Dan Fedor knows billing and reimbursement. Here are his previous articles in case you need them.
Prepayment Reviews of Tile (E1002) and Tile and Recline (E1007) are Coming – Heads Up!
Fedor: No G Code May Increase Reviews On Power Mobility Devices