New power mobility codes revised, delayed
BALTIMORE - As a result of discussions with manufacturers, suppliers and clinicians, the DME Program Safeguard Contractors announced last week that they have revised the coverage criteria for power mobility devices.
One highlight of the revised Local Coverage Determination (LCD), is the elimination of the automatic "downcoding" to Group I power wheelchairs if the patient does not meet coverage for a Group II or higher chair. The announcement from the Region A/B PSC states, "One of the changes that has been made in the policy is to eliminate the least costly alternative determination that would have downcoded Group 2 to Group 1 power wheelchairs."
Additionally, CMS announced that it would delay implementing the new codes and coverage criteria until Nov. 15, 2006 and indicated the fee schedules for the new PMD codes "should be available in the near future." The codes were originally scheduled to take effect Oct. 1.
In a bulletin announcing the delay and revision, the Region A/B DME PSC, Tricenturion, stated the following:
It is also important for suppliers and clinicians to be aware that, as with all Local Coverage Determinations (LCDs), individual consideration is available through two avenues for claims that do not meet the stated coverage criteria in the policy.
1. The Advance Determination of Medicare Coverage (ADMC) process is available for those power wheelchairs that are eligible for ADMC. If there is an affirmative determination on the ADMC request, the supplier may then add the KX modifier to the claim.
2. In the absence of ADMC approval, if a claim is submitted without a KX modifier for a PMD that doesn't meet the coverage criteria stated in the policy and the claim is denied, individual consideration can be sought through the appeals process.
One example (not all-inclusive) would be a patient with a progressive neurological disease, such as amyotrophic lateral sclerosis (ALS) or multiple sclerosis (MS), who does not yet meet coverage criteria for a Group 3 power wheelchair but where the documentation from the face-to-face examination supports the need for a higher level PWC in the near future. .
The revisions of the Power Mobility Devices LCD and Policy Article as well as the Wheelchair Options and Accessories and Wheelchair Seating LCDs and Policy Articles can be found on the Tricenturion web site at www.tricenturion.com.