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Reimbursement News! Reclassification of Wheelchair Accessories

Posted on in Billing/Reimbursement

By Dan Fedor, Reimbursement Specialist, U.S. Rehab

There have been several major changes implemented in July that impact the payment category of some common wheelchair accessories and required modifiers.   

If the accessory is capped rental and it is being used on a complex rehab power base (K0835-K0864), the accessory has the first-month purchase option. If the accessory is capped rental and it is being used on a standard (not complex rehab) power base (everything below a K0835), the accessory DOES NOT have the first-month purchase option and can only be rented for up to 13 months even as a replacement/repair until Oct. 1, 2016, where all replacements as a repair will be paid on a lump sum bases (more details to come on this).

Rule of thumb: If the base has the first-month purchase option, the capped rental accessory has the first-month purchase option. If the base does not have the first-month purchase option, the capped rental accessory does not have the first-month purchase option and can only be rented even as replacement until Oct. 1, 2016, as stated above. All examples already currently effective other than where noted. Click on the following links to view MLN Matters for reference: MM8566 and MM8822.

EXAMPLES

Please note when there are more than four modifiers required, the “99” must be used in the fourth position and additional modifiers added in the extra narrative field.

  • Capped rental replacement part (E2374) on a Group 2 complex power base (K0835-K0864) regardless of where the beneficiary resides:
    • Joystick E2374 NUKHBPRBKX 
  • Capped rental replacement part (E2374) on a Group 3 complex power base (K0848-K0864) regardless of where the beneficiary resides:
    • Joystick E2374 NUKHBPRBKUKX 
  • Capped rental replacement part (E2374) on Group 1 and Group 2 non-complex power base (regardless of where the beneficiary resides):
    • Joystick E2374 RRKHRBKX (first month, then follow usual capped rental modifiers for subsequent months: KI months 2 and 3 and KJ months 4-13)
  • Capped rental replacement part (E2370) on a Group 2 complex power base (K0835-K0843) regardless of where the beneficiary resides:
    • Motor/Gear E2370 NUKHBPRBKX 
  • Capped rental replacement part (E2370) on a Group 3 complex power base (K0848-K0864) regardless of where the beneficiary resides:
    • Motor/Gear E2370 NUKHBPRBKUKX 
  • Capped rental replacement part (E2370) on Group 1 and Group 2 non-complex power bases (regardless of where the beneficiary resides):
    • Motor/Gear E2370 RRKHRBKX (first month then follow usual capped rental modifiers for subsequent months: KI months 2 and 3 and KJ months 4-13)
  • Capped rental accessory (E0955) provided on a Group 2 complex power base when beneficiary resides in competitive bid area:
    • Headrest E0955 NUKHBPKYKX)
    • In the nine round 1 CBAs, the headrest doesn't become a capped rental until Jan. 1, 2017
  • Capped rental accessory (E0955) provided on a Group 2 complex power base when beneficiary does NOT reside in competitive bid area:
    • Headrest E0955: NUKHBPKX
    • In the nine round 1 CBAs, the headrest doesn't become a capped rental until Jan. 1, 2017
    • Capped rental accessory (E0955) provided on a Group 3 complex power base regardless of where the beneficiary resides:  
      • Headrest E0955 NUKHBPKUKX
      • In the nine round 1 CBAs, the headrest doesn't become a capped rental until Jan. 1, 2017 (remains IRP)
    • Capped rental accessory (E1002) provided on a Group 2 complex rehab power base regardless of where the beneficiary resides:
      • E1002 NUKHBPKX
    • Capped rental accessory (E1002) provided on a Group 3 complex rehab power base regardless of where the beneficiary resides:
      • E1002 NUKHBPKUKX
    • Capped rental accessory (E0955) provided on a complex manual base (K0005, E1161) when the beneficiary resides in a competitive bid area:    
      • Headrest E0955 RRKHKYKX (then follow capped rental KI for months 2 and 3 and KJ months 4-13)
      • In the nine round 1 CBAs, the headrest doesn't become a capped rental until Jan. 1, 2017 (remain IRP)
    • Capped rental accessory (E0955) provided on a complex manual base (K0005, E1161) when the beneficiary does NOT reside in a competitive bid area:    
      • Headrest E0955 RRKHKX (then follow capped rental KI for months 2 and 3 and KJ months 4-13)
      • In the nine round 1 CBAs, the headrest doesn't become a capped rental until Jan. 1, 2017 (remains IRP)

    The DME MACs have indicated that the KY modifier can’t be used with a replacement associated with a repair to the base item (when RB modifier is required). The KY modifier may be used when the competitive bid accessory is used on a non-bid complex base (K5, E1161, K0835-K0864) and the beneficiary resides in a CB area. This enables the system to use the 2016 Adjusted Fee Schedule rather than the single-payment amount (SPA).

    The KU modifier can be used for all affected accessories and parts listed here when used on a Group 3 complex rehab power base from July 5 – Dec. 31, 2016. This enables the system to use the 2016 Unadjusted Fee Schedule rather than the 2016 Adjusted Fee Schedule.

    If you have any questions, please contact me at 844-794-8459 or dan.fedor@vgm.com.

     

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