Ask the PSC MDs

Saturday, September 30, 2006

Many of the columns for the past few months have focused on power mobility issues. This month we will look at a potpourri of topics that come our way. Most of the questions we address are general in nature. We select them that way to be applicable to the broadest audience. Some of the following are more specific and technical, but we think you will find them interesting and useful.
Q. Currently, if a respiratory assist device without back-up rate (E0470) is billed and the LCD criteria are not met but the coverage criteria for CPAP (E0601) are met, payment is based on the allowance for the least costly medically appropriate alternative, E0601. The current RAD LCD states that if a respiratory assist device with back-up rate (E0471) is billed and the criteria are not met, it will be denied as not medically necessary because E0471 is in a different payment category. With the E0471, E0470, and the E0601 now in the same payment category, will the LCD be revised to allow the downcode from E0471 to E0470 to occur?
A. Yes, watch for a future revision to the RAD LCD to provide for the least costly alternative provision to be applied to E0471.
Q. Are oximetry tests from a nursing home acceptable as long as the customer was in a Part A bed at the time of the test?
A. Assuming the SNF is a qualified provider of laboratory services, yes.
Q. The Power Mobility Devices Policy states that a detailed order product description must list the specific power chair being ordered. Does this refer to the specific code or the manufacturer and/or the specific model? If it is the manufacturer or the model, what does the supplier do if it is necessary to change the specific chair within a HCPCS code category?
A. The detailed product information must accurately describe the item(s) provided, which includes, but is not limited to, manufacturer and specific model number and appropriate HCPCS code. If last-minute changes or substitutions are made the documents must be updated/revised accordingly.
Q. For patients with progressive neurological conditions who do not meet coverage criteria for a Group 3 power wheelchair now (i.e., they are able to stand and pivot to transfer) but are very likely to progress and meet the criteria for a Group 3 over the next 6 months to a year, would a Group 3 chair be covered?
A. Medicare's general rule is that coverage is based on the patient's current medical condition on or around the date of service. On a case-by-case basis, it is possible that individual consideration could be given to consider whether a more advanced product might be eligible for reimbursement. Extensive documentation regarding the patient's medical condition and progression of disease would be required. In this scenario, if a Group 3 chair is provided, the KX modifier may not be added to the code and the additional documentation should be included with the reconsideration request.
Q. Medicare has said that if a patient needs a PMD inside the home, that they may use it outside the home. However, coverage criteria are based on use within the home. A PMD that is adequate for use in the home may, be unsafe for the patient to use in certain situations (e.g., steeper inclines) outside the home. Medicare is forcing the physician/clinician to order an inappropriate PMD.
A. There is a statutory limitation on the types of items that are eligible for coverage under the DME benefit. It covers items and features that are medically necessary within the home. The coverage criteria in the PMD LCD are based on these statutory limitations. If the beneficiary wants features beyond what the physician orders, equipment upgrade provisions exist that allow the supplier to bill appropriately.