Close

Prepayment Reviews of Tilt (E1002) and Tilt and Recline (E1007) are Coming - Heads Up!

Posted on in Billing/Reimbursement

PrepaymentReviewsOn April 28, 2015, DME MAC C released a notice that they will be implementing a Prepayment Review for HCPCS Codes E1002 (power tilt) and E1007 (power tilt AND recline). Claims subjected to this review will be developed for additional documentation via an Additional Documentation Request (ADR). Please adhere to these requests by providing the documentation requested in a timely manner. The information must be received within 45 days from the date of the letter or the claim will be denied. Even though this is a DME MAC C prepay, please know that the other DME MACs will likely follow and implement a prepay review on these items as well. Regardless of a prepay review the following information is important for ADMC and post pay audits. If the tilt or tilt and recline is denied, the power wheelchair base will also be denied along with the associated accessories. This is because the single power and multiple power bases are contingent upon the power seating systems (tilt or tilt and recline), therefore, if the power seating system is denied the base along with associated accessories will deny. Since this is NOT a prior authorization but rather a prepayment review, the item must be provided prior to submission of the claim. Therefore it is critical to ensure you have the necessary documentation to justify the need for these products. Medical Justification E1002 - Tilt ONLY

  • The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift; OR
  • The power seating system is needed to manage increased tone or spasticity
If the tilt is being provided for pressure relief the patient must have a qualifying diagnosis for a skin protection cushion (see wheelchair seating policy for diagnosis codes) otherwise the tilt, cushion, base and all accessories will be denied. E1007 - Tilt AND Recline
  • The beneficiary is at high risk for development of a pressure ulcer and is unable to perform a functional weight shift AND
  • The beneficiary utilizes intermittent catheterization for bladder management and is unable to independently transfer from the wheelchair to bed; OR
  • The power seating system is needed to manage increased tone or spasticity
For clarification, the LCD for tilt and tilt and recline has NOT changed. The “AND” above is not a typo and was intentional. We've seen Medicare question why a beneficiary requires both when the only reason noted that the patient can't perform a functional weight shift (pressure relief/redistribution). If there are other reasons, such as to manage tone and spasticity or for intermittent catheterization for bladder management, then they allow both without question. The other reason for this is a tilt is sometime provided alone when a patient can't perform a functional weight shift to manage pressure redistribution, so their thinking is why does it work for some for pressure redistribution but not for others and since a tilt alone is a least costly alternative, it would be wise to obtain a complete detailed reason as to why both are medically necessary for a specific patient. Many VGM and U.S. Rehab members have told me that they are confident they would win an appeal if a tilt and recline were denied if the only reason listed was for pressure redistribution (relief), however it is not a good business decision to rely on an appeal as we all know they are taking approximately two years. So the advice here is an ounce of prevention (more details as to why the patient requires both) is worth a pound of cure (waiting two years for reimbursement). You may be right in that the LCD doesn't differentiate coverage from a tilt to a tilt and recline however knowing the scrutiny on PMD claims and the fact that appeals (ALJ level) is out about two years, it is wise to advise therapists to be very specific when documenting why a patient requires all separately reimbursable accessories. Again the purpose of this information is to ensure you are protected from unnecessary denials and appeals. If the tilt AND recline is provide for pressure redistribution/relief the patient must have a qualifying diagnosis for a skin protection cushion (see wheelchair seating policy for diagnosis codes) AND there must be either another reason for the recline as noted above OR additional narrative from a clinician as to why the tilt with a skin protection cushion alone does not provide adequate pressure redistribution/relief. Please ensure that the documentation from the clinicians to justify the medical necessity for these accessories (and any accessory) is specific to the patient and is NOT a check off or canned answer. The narrative must be specific as to why this patient requires the item. Proper Base Coding In addition, please ensure that base code selected is accurate for the seating system being provided. Single Power Bases - Must have either a tilt OR recline OR alternative drive device (other than standard joystick). Multiple Power Bases - Must have a tilt AND recline OR a ventilator that is used on the power wheelchair. We have seen many denials through ADMC recently where the base code was K0861 (group 3 multiple power) with an E1002 (tilt ONLY). Even if this power wheelchair has power ELRs or a center mount articulating foot platform, it is still a single power base and therefore the proper code would be a K0856 (group 3 single power base). Examples of Proper Base Coding (standard up to and including 300 pounds)

Single Power K0835 (group 2 standard) OR K0856 (group 3 standard) single power base E1002 - Tilt ONLY E1010 - Power ELRs

Multiple Power K0861 (group 3 standard) multiple power base E1007 - Tilt AND Recline Click here to read the complete article from DME MAC C.

ADMC Update A bit of good news was received from DME MAC C regarding this prepayment review in that when a favorable ADMC is obtained, those claims will NOT be subject to this prepay review. ADMC is available for these items when provided on a new base so I would advise you to take advantage of that program. For clarification, the LCD for tilt and tilt and recline has NOT changed.
For additional information please register for the webinar titled:

Audits for complex Rehab Accessories are coming! Be prepared! Thursday May 14 at 10 a.m. CST

REGISTER NOW If you have any questions regarding this article or the coverage criteria for power seating systems please contact Dan Fedor at dan.fedor@vgm.com or 844-794-8459.

 

Tags: