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Every PENNY Counts - Don't Leave MONEY on the Table for CRT Accessories

Posted on in Billing/Reimbursement

By: Dan Fedor, U.S. Rehab

If you provide CRT accessories, you may be leaving money on the table if you are not using the proper modifiers and are not tracking underpayments for Group 3 accessories from Jan 1 - June 30. One, if the beneficiary resides in a competitive bid (CB) area and you provide a bid accessory on a non-bid complex rehab wheelchair base (K0835-K0864, K0005 and E1161), you should be paid at the current 2016 fee schedule, which is based on the competitive bid adjusted rates and not the competitive bid contacted rate (single-payment amount (SPA)) for that competitive bid area.

In addition, accessories used on Group 3 complex rehab power bases should then pay an additional amount above the 2016 CB adjusted fee schedule due to a law that was passed on Dec. 28, 2015, which exempted Group 3 accessories from competitive bid pricing until Jan 1, 2017.

Beneficiary Resides in Competitive Bid Area

When the beneficiary resides in a competitive bidding area and a competitive bid accessory is billed, the system defaults to pay it at the competitive bid SPA for that area. For example, if an E0955 (headrest) is billed in the competitive bid area of Chattanooga, Tenn., on a complex rehab power base, it will default to pay at the SPA, which is $139.77 if the correct pricing modifiers are not used on that line item. In order to obtain the accurate allowable for this situation, a KY modifier would be used to inform Medicare that while this is a competitive bid accessory, it is being used on a complex rehab power base (K0835) and, therefore, should pay at the current fee schedule ($164.41 for non-rural in this example) and NOT the SPA ($139.77). If this one accessory alone is not billed properly, your company is losing $24.64. Remember: EVERY PENNY COUNTS! And, for a complex manual base (K0005/E1161), the KY and KE modifiers would be used for E0955, which would result in an allowed amount of $179.85. That's a loss of $40.08 on just the headrest alone. Add this up with all accessories, and it could be somewhat significant.

  • If the beneficiary resides in a competitive bid are, and the accessory is a bid item being used on a non-bid complex rehab power base (K0835-K0864), then the KY modifier should be used to ensure accurate reimbursement. 
  • If the beneficiary resides in a competitive bid area and the accessory is a bid item being used on a non-bid complex rehab power base (K0005, E1161), then the KY and KE modifiers should be used to ensure accurate reimbursement. 

If these modifiers are not used, your company is leaving money on the table.

Group 3 Power Wheelchair Bases (K0848-K0864)

A law was passed on Dec. 28, 2015, delaying the implementation of CB pricing on accessories used with Group 3 power wheelchairs until Jan. 1, 2017. This means that Medicare is not to implement CB pricing on wheelchair accessories when used on Group 3 power wheelchairs from Jan. 1, 2016 – Dec. 31, 2016. However, Medicare has indicated that they won't be updating their system to pay accurately for these until July 1, 2016. Therefore, the provider should be tracking all wheelchair accessories provided on a Group 3 power wheelchairs from Jan. 1 - June 30 and comparing the amount allowed to the 2015 fee schedule to determine the amount of underpayment and the amount due come July 2016. This report should be ready to submit as a written reopening in early July to have those accessories adjusted for proper payment.

If the beneficiary resides in a competitive bid area and the accessory is a bid item being used on a Group 3 complex rehab power base, then it will allow the 2016 fee schedule when a KY modifier is used from Jan. 1 - June 30. However, you are entitled to the 2015 fee schedule (approximate) due to the exemption of applying competitive bid adjusted pricing on accessories when used on Group 3 power chairs. The DME MAC stated they won't update their system to pay these accurately (at the 2015 fee schedule) until July 1, 2016, so claims from Jan. 1 - June 30 will be underpaid even if the provider bills correctly. In this case, providers must track these accessories on a spreadsheet and request a written reopening in July 2016 to obtain accurate reimbursement. For the Group 3 example, a provider would bill an E0955 with a KY modifier for pricing and receive $164.41; however, this should pay at approximately $193.43 in Tennessee. An additional amount would be due the provider of $29.02, which can be recouped in July 2016. So, if the proper modifier (KY) is not used and these claims are not tracked and reopened in July, a provider would lose $53.66 just on the headrest alone when the beneficiary resides in a competitive bid area.

Non-Competitive Bid Areas

When the beneficiary does NOT reside in a competitive bid area, providers are still being underpaid from Jan. 1 - June 30 and should still track all accessories provided with Group 3 power chair bases. The determination of the allowable will be based on the beneficiary's zip code (rural or non-rural). We will use rural Tennessee for this example. In this case the provider would be paid on the E0955 at $171.04 and should be paid $193.43. This is an underpayment of $22.39 for just the headrest. The provider will recoup this underpayment in July when a written reopening is requested.

Keep in mind, I'm only giving an example of one accessory as there are many more affected by this, and if providers are not tracking these underpayments, they are leaving money on the table.

Example of Power Tilt and Related Electronics (regardless of where the beneficiary resides)

When billing a power tilt (E1002) and electronics (E2310), the allowed amount from Jan. 1 - June 30 will be based on the current 2016 fee schedule. 

2016 Fee Schedule

E1002 - $3,644.60
E2310 - $1,059.30

Total Allowed - $4,703.90

Here is the accurate allowable for these items (approximate 2015 fee schedule):

E1002 - $3,877.40
E2310 - $1,119.40

Total Allowed - $4,996.80

Total Due Provider in July - $292.90

Just with these two items, a provider is being underpaid (allowable) from Jan. 1 - June 30 by $292.90.

Providers should track all accessories provided on Group 3 power bases to calculate the amount owed in July. Compare the allowed amount to the 2015 fee schedule, and the difference is the allowed amount due. In order to obtain this, a provider would need to request a written reopening once the system is updated to pay properly, which we are told will be in July.

Below are the allowed amounts in the competitive bidding areas (SPA):

Round 1 Recompete SPAs on standard mobility equipment and related accessories
Round 2 Recompete SPAs on standard wheelchairs, scooters and related accessories

Click here for the fee schedule to determine the 2016 allowable compared to the 2015 allowable for each code affected.

There will be a webinar to further explain the content in this article on Thursday, April 28 from 10-11 a.m. CDT: Every PENNY Counts - Don't Leave MONEY on the Table for CRT Accessories  - Click here to register.

 

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