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Footing the Bill for Wheelchairs

Article originally featured on HomeCare Magazine

Keeping up with reimbursement, documentation and changing payer needs is tough enough when there isn’t a pandemic going on. With COVID-19 and new rules about virtual contact, there’s even more to know. HomeCare spoke with Dan Fedor, director of reimbursement and education for U.S. Rehab, about the latest in mobility-related billing.

HOMECARE: What’s new out there in terms of billing and reimbursement for mobility equipment?

FEDOR: There’s a lot, of course. There is always a lot going on, but especially with the pandemic. Because of the COVID-19 public health emergency, a lot has changed in terms of waivers. With regard to mobility waivers, which took effect last spring, the Centers for Medicare & Medicaid Services (CMS) is allowing in-person encounters to be virtual. Normally you’d need a face-to-face (FTF) with a practitioner, a therapist evaluation, the assistive technology professional (ATP) assessment for complex rehab and the home assessment would be in person. In some cases you just can’t do a virtual visit based on the person and the situation, but many providers are utilizing that waiver because patients and locations don’t want contact and they want to keep the patient protected. … It’s sad that a pandemic caused this realization by CMS that some things can be virtual, that you don’t have to be in person all the time. … It makes everybody more efficient, especially for the patient in a wheelchair for whom it’s difficult to travel. It’s just a win-win all around. I hate to use that term—but all around it’s helpful for the patient, the practitioner and the provider.

HOMECARE: Do you think the virtual option will stick around after the pandemic ends? When will we know for sure?

FEDOR: The rumbling within CMS and the industry is that this will likely remain, and we really don’t know when that announcement will happen. It depends when the public health emergency ends and then if they say “we are extending this.” For the licensed/certified medical professional (LCMP) evaluation, we’re not sure—that may or may not continue to be virtual. The ATP evaluation will probably not and the home assessment may not for complex rehab technology and maybe also for standard power and manual chairs.

Either way, the pandemic opened CMS’s eyes to a couple of things. First, virtual is an option; of course, people will abuse it like they do anything and you have to have safeguards in place. And second, how valuable homecare is compared to putting someone in the hospital or in a nursing home. I think that’s a huge thing for the patients and the providers and the industry as a whole.

FEDOR: One of the things I see lacking with virtual is the details. I think some people think that because the in-person isn’t required, all that doesn’t need to be there. But it does. For example, if they’re documenting that someone needs power mobility, they have to rule out the less costly alternatives, and they have to have a reason. You can’t just say “weakness” and “it’s virtual so we don’t have a manual muscle test”—you still have to do it. The question is, how can we do a manual muscle test online, how do we do a virtual range of motion? That’s the future, but virtually, it’s more challenging—it’s not something people are trained to do. … The FTF with the ordering practitioner is easier because they don’t provide objective measurements.

HOMECARE: Switching gears, let’s talk a little bit about Medicare Advantage (MA) plans when it comes to mobility reimbursement. This is something you’ve spoken quite plainly about. There are some issues, right?

DAN FEDOR: It’s very frustrating. I’ve been in this industry since 1993; I started with Medicare; I worked for six years as a contractor and then I went to Pride. My goal in doing this work is being able to help people get their products and navigate their insurance hurdles. That’s given me the satisfaction of doing the job. Now I sit in my home office and I have the weather channel or whatever playing in the background and I’m just bombarded with celebrities—with Joe Namath and everyone—talking about how great their Advantage plan is.

At the same time, I’m getting emails from members and from suppliers saying this Advantage plan is denying my claim inappropriately. There are all these challenges, and as you know it’s not just one, there are so many. I really feel for suppliers, when their goal is to provide patients with mobility products and they have to deal with all of this.

For example, I just talked to somebody yesterday about an Advantage plan; there’s an ALS patient with a Group 3 complex rehab chair, and they want to pay it as a rental. And the representative there says, “Because when I look in the Medicare fee schedule, it only has (the RR modifier) for rental.” … But Medicare allows for purchase. They know that they’re putting the provider in the middle because the patient needs it and the provider needs to service patients and the provider if the provider needs to go back and say to the patient “I can’t rent this,” the provider looks like the bad guy.

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HOMECARE: What can providers do when this happens?

FEDOR: In this case, I copied the page out of the Medicare supplier manual—from the DMEPOS fee schedule chapter, where it specifically states what is allowed under complex rehab and gives the codes K0835-K0864—I copied it and and sent it to the provider so they can show them that it is an RR modifier but there is a purchase option. Then, option two is to let the patient know you can’t do it. I would tell the patient, “Your insurance will not pay for this as a purchase; you can talk to your insurance or you can switch back to Medicare fee-for-service.” That’s the only thing that really gets the attention of these private advantage plans, because then they’ll lose customers.

HOMECARE: Are there new trends or shifts we should be looking for on the horizon?

FEDOR: One thing to note is that there’s been a submission to CMS for a national coverage determination for the power elevating seat and the power standing features; those are in a noncovered category. Medicare calls them a convenience item, and that’s why they don’t pay. NCART and others, including clinicians, have been talking about why this is not a convenience, about the medical necessity, and they were submitted back in September for CMS to consider as covered items. That would be huge if it goes through. It opens a huge door and a benefit for patients.

HOMECARE: Anything else providers need to be aware of?

FEDOR: It never hurts to throw out a reminder that prior authorization doesn’t review all the accessories. It reviews the base code and the accessories that the base code is contingent on, but none of the others. So if, say, they have K0861, a Group 3 multiple power chair with tilt and recline on it, they review that the patient is eligible for the base code, and they also verify the patient is eligible for the associated accessories. But a complex rehab claim has multiple lines, maybe 13 or 14 lines of accessories—and those go through, too. What I’m worried about is post-pay audits. A lot of providers are not getting electronics documented but they’re getting paid. They need to make sure that everything they submit meets the coverage criteria, and that they hang onto the documentation in case of a post-pay audit.


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