Article - Power Mobility Devices - Policy Article (A52498)

CMS National Coverage PolicyN/AArticle TextNON-MEDICAL NECESSITY COVERAGE AND PAYMENT RULESFor any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare statutory and regulatory requirements. Information provided in this policy article relates to determinations other than those based on Social Security Act 1862(a)(1)(A) provisions (i.e. reasonable and necessary).Power mobility devices are covered under the Durable Medical Equipment benefit (Social Security Act 1861(s)(6)). In order for a beneficiarys equipment to be eligible for reimbursement the reasonable and necessary (R&N) requirements set out in the related Local Coverage Determination must be met. In addition, there are specific statutory payment policy requirements, discussed below, that also must be met.The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, added section 1834(a)(1)(E)(iv) which provides that payment may not be made for a motorized or power wheelchair unless the treating practitioner conducts the face-to-face encounter and writes the Standard Written Order (SWO). If the treating practitioner does not conduct the face-to-face encounter or write the SWO for the PMD base item, the claim will be denied as statutorily noncovered.A power mobility device may not be ordered by a podiatrist. If it is, it will be denied as statutorily noncovered.FACE-TO-FACE ENCOUNTER:If the POV or PWC is a replacement during the 5-year useful lifetime of an item in the same performance group that was previously covered by Medicare, a face-to-face encounter is not required. Note: Replacement during an items useful lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural disaster (e.g., fire, flood, etc.).The treating practitioner may conduct the entire mobility face-to-face encounter or may refer the beneficiary to a licensed/certified medical professional (LCMP), such as a physical therapist (PT) or occupational therapist (OT), who has experience and training in mobility evaluations to perform part of the face-to-face encounter. This person may have no financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, the PT or OT working in the inpatient or outpatient hospital setting may perform part of the face-to-face encounter.)To accommodate the requirements at 42 CFR 410.38, when the treating practitioner sees the beneficiary, regardless of whether a referral to an LCMP is made, that visit date starts the six (6) month timeline for completion of the SWO for the wheelchair base. If the treating practitioner chooses to refer the beneficiary to an LCMP for a mobility evaluation, the treating practitioner's co-signature, dating and indicating agreement or disagreement with the LCMP evaluation must occur within this six (6) month timeframe. In cases where the LCMP evaluation is being adopted into the practitioner's documentation to substantiate the need for the base item, the SWO may not be written until the LCMP report is signed, dated and agreement/disagreement indicated.MISCELLANEOUS:A custom motorized/power wheelchair base (K0013) must be uniquely constructed or substantially modified for a specific beneficiary according to the description and orders of the beneficiarys treating practitioner. The beneficiarys needs must not be able to be accommodated by any other existing PMD and accessories, including customized seating arrangements. See 42 CFR Section 414.224(a).If any POV or PWC is only for use outside the home, it will be denied as noncovered.Reimbursement for the wheelchair codes includes all labor charges involved in the assembly of the wheelchair. Reimbursement also includes support services, such as delivery, set-up, and education about the use of the PMD.Upgrades that are beneficial primarily in allowing the beneficiary to perform leisure or recreational activities are noncovered.REQUIREMENTS FOR SPECIFIC DMEPOS ITEMS PURSUANT TO Final Rule 1713 (84 Fed. Reg Vol 217)Final Rule 1713 (84 Fed. Reg Vol 217) requires a face-to-face encounter and a Written Order Prior to Delivery (WOPD) for specified HCPCS codes. CMS and the DME MACs provide a list of the specified codes, which is periodically updated. The required Face-to-Face Encounter and Written Order Prior to Delivery List is availablehere.Claims for the specified items subject to Final Rule 1713 (84 Fed. Reg Vol 217) that do not meet the face-to-face encounter and WOPD requirements specified in the LCD-related Standard Documentation Requirements Article (A55426) will be denied as not reasonable and necessary.If a supplier delivers an item prior to receipt of a WOPD, it will be denied as not reasonable and necessary. If the WOPD is not obtained prior to delivery, payment will not be made for that item even if a WOPD is subsequently obtained by the supplier. If a similar item is subsequently provided by an unrelated supplier who has obtained a WOPD, it will be eligible for coverage.POLICY SPECIFIC DOCUMENTATIONIn addition to policy specific documentation requirements, there are general documentation requirements that are applicable to all DMEPOS policies. These general requirements are located in the DOCUMENTATION REQUIREMENTS section of the LCD.Refer to the LCD-related Standard Documentation Requirements article, located at the bottom of this Policy Article under the Related Local Coverage Documents section for additional information regarding GENERAL DOCUMENTATION REQUIREMENTS and the POLICY SPECIFIC DOCUMENTATION REQUIREMENTS discussed below.If documentation of the medical necessity for a K0013 wheelchair is requested, contractors must be able to determine that the item delivered is a customized item. Documentation must include a description of the beneficiarys unique physical and functional characteristics that require a custom motorized/power wheelchair base. This must include a detailed description of the manufacturing of the wheelchair base, including types of materials used in custom fabricating or substantially modifying it, and the construction process and labor skills required to modify it. The record must document that the needs of the beneficiary cannot be met using another power wheelchair base that incorporates seating modifications or other options or accessories (prefabricated and/or custom). The documentation must demonstrate that the K0013 is so different from another power wheelchair base that the two items cannot be grouped together for pricing purposes.SPECIALTY EVALUATION:The specialty evaluation provides detailed information explaining why each specific option or accessory  i.e., power seating system, alternate drive control interface, or push-rim activated power assist  is needed to address the beneficiarys mobility limitation. There must be a written report of this evaluation available on request. The PT, OT, or practitioner who performs the specialty evaluation may have no financial relationship with the supplier. (Exception: If the supplier is owned by a hospital, the PT, OT, or practitioner working in the inpatient or outpatient hospital setting may perform the specialty evaluation.)MODIFIERSKX, GA, GY, AND GZ MODIFIERS:If the requirements related to a face-to-face encounter have not been met, the GY modifier must be added to the codes for the power mobility device and all accessories.If the power mobility device or push-rim activated power assist device that is provided is only needed for mobility outside the home, the GY modifier must be added to the codes for the item and all accessories.A KX modifier may be added to the code for a power mobility device and all accessories only if one of the following conditions is met:If all of the coverage criteria specified in the related LCD have been met for the product that is provided; orIf there is an affirmative Advance Determination of Medicare Coverage (ADMC) for the product that is provided.If the requirements for use of the KX modifier or GY modifier are not met, the GA or GZ modifier must be added to the code. When there is an expectation of a medical necessity denial, suppliers must enter GA on the claim line if they have obtained a properly executed Advance Beneficiary Notice (ABN) or GZ if they have not obtained a valid ABN.Claim lines billed without a KX, GA, GY, or GZ modifier will be rejected as missing information.CODING GUIDELINESDEFINITIONS:Power Mobility Device (PMD) - Base codes include both integral frame and modular construction type power wheelchairs (PWCs) and power operated vehicles (POVs).Power Wheelchair - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated or modular seating system, electronic steering, and four or more wheel non-highway construction.Power Operated Vehicle - Chair-like battery powered mobility device for people with difficulty walking due to illness or disability, with integrated seating system, tiller steering, and three or four-wheel non-highway construction.Beneficiary Weight Capacity  The terms Standard Duty, Heavy Duty, etc., refer to weight capacity, not performance. For example, the term Group 3 heavy duty power wheelchair denotes that the PWC has Group 3 performance characteristics and beneficiary weight handling capacity between 301 and 450 pounds. A device is not required to carry all the weight listed in the class of devices, but must have a beneficiary weight capacity within the range to be included. For example, a PMD that has a weight capacity of 400 pounds is coded as a Heavy Duty device.Portable - A category of devices with lightweight construction or ability to disassemble into lightweight components that allows easy placement into a vehicle for use in a distant location.Performance Testing - Term used to denote the RESNA based test parameters used to test PMDs. The PMD is expected to meet or exceed the listed performance and durability figures for the category in which it is to be used when tested. There is no requirement to test the PMD with all possible accessories.Test Standards - Performance and durability acceptance criteria defined by ANSI/RESNA standard testing protocols.Crash Testing - Successful completion of WC-19 testing.Top End Speed - Minimum speed acceptable for a given category of devices. It is to be determined by the RESNA test for maximum speed on a flat hard surface.Range - Minimum distance acceptable for a given category of devices on a single charge of the batteries. It is to be determined by the appropriate RESNA test for range.Obstacle Climb - Vertical height of a solid obstruction that can be climbed using the standing and/or 0.5 meter run-up RESNA test.Dynamic Stability Incline - The minimum degree of slope at which the PMD in the most common seating and positioning configuration(s) remains stable at the required beneficiary weight capacity. If the PMD is stable at only one configuration, the PMD may have protective mechanisms that prevent climbing inclines in configurations that may be unstable.Radius Pivot Turn  The distance required for the smallest turning radius of the PMD base. This measurement is equivalent to the minimum turning radius specified in the ANSI/RESNA bulletins.PWC Basic Equipment Package - Each power wheelchair code is required to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue, unless otherwise noted). The statement that an item may be separately billed does not necessarily indicate coverage.Lap belt or safety belt. Shoulder harness/straps or chest straps/vest may be billed separately.Battery charger, single modeComplete set of tires and casters, any typeLegrests. There is no separate billing/payment if fixed, swingaway, or detachable non-elevating legrests with or without calf pad are provided. Elevating legrests may be billed separately.Footrests/foot platform. There is no separate billing/payment if fixed, swingaway, or detachable footrests or a foot platform without angle adjustment are provided. There is no separate billing for angle adjustable footplates with Group 1 or 2 PWCs. Angle adjustable footplates may be billed separately with Group 3, 4 and 5 PWCs.Armrests. There is no separate billing/ payment if fixed, swingaway, or detachable non-adjustable height armrests with arm pad are provided. Adjustable height armrests may be billed separately.Any weight specific components (braces, bars, upholstery, brackets, motors, gears, etc.) as required by beneficiary weight capacity.Any seat width and depth. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:For Standard Duty, seat width and/or depth greater than 20 inches;For Heavy Duty, seat width and/or depth greater than 22 inches;For Very Heavy Duty, seat width and/or depth greater than 24 inches;For Extra Heavy Duty, no separate billingAny back width. Exception: For Group 3 and 4 PWCs with a sling/solid seat/back, the following may be billed separately:For Standard Duty, seat back width greater than 20 inches;For Heavy Duty, back width greater than 22 inches;For Very Heavy Duty, back width greater than 24 inches;For Extra Heavy Duty, no separate billingController and Input DeviceThere is no separate billing/payment if a non-expandable controller and a standard proportional joystick (integrated or remote) is provided. An expandable controller, a nonstandard joystick (i.e., nonproportional or mini, compact or short throw proportional), or other alternative control device may be billed separately.Refer to the bundling table in the Wheelchair Options/Accessories Policy Article for a list of codes that are not separately billable at the time of initial issue of a PWC.POV Basic Equipment Package - Each POV is to include all these items on initial issue (i.e., no separate billing/payment at the time of initial issue):Battery or batteries required for operationBattery charger, single modeWeight appropriate upholstery and seating systemTiller steeringNon-expandable controller with proportional response to inputComplete set of tiresAll accessories needed for safe operation