Saturday, January 31, 2004

Coverage criteria changes
With J. Everett Wilson

Q. I heard that Medicare passed new regulations regarding power wheelchairs. Is that true, am I affected, and how do I comply?

A. Your fellow supplier is correct, and you are definitely affected by the new regulation. All DMERCs are now strictly enforcing the coverage criteria for power wheelchairs and applying them to all claims reviewed regardless of the date of service or date of submission. Specifically, suppliers are being asked to provide relevant portions of patient medical records containing evaluations performed and recorded prior to the delivery of power wheelchairs. These records must include physician notes and non-physician clinician notes from medical offices, inpatient or outpatient hospitals and nursing homes. They must reference the patient’s ability to walk, either independently or with a walker, as well as the strength and function of their upper extremities and the diagnosis associated with their physical limitations. Without these medical records, DMERCs will deny the claims.

It is important to be proactive and obtain these records upfront, as most medical practices and facilities will be more inclined to provide the documents upon writing the order rather than months later. In addition, if the documents received do not adequately address the DMERC’s requirements, DMEs should then address it with the referring provider to obtain the necessary documentation. If there is ever an inquiry in the future, these proactive efforts to obtain the necessary documentation will be well worth the initial effort.

J. Everett Wilson, Esq., is managing partner at Wilson Suarez Lopez & Gennett: (305) 446-7300