Reimbursement

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Monday, September 30, 2002

Our friend, the K0011 wheelchair
WITH BRUCE BOTHIS
Q. With all I'm seeing in the trade regarding documentation for K0011s, what do I truly need to get paid?

A. Well, the answer is both simple and complicated at the same time. Confused? So is most of the industry. CMS's recent ruling requiring the DMERCs to process claims based solely on the merits of the CMN has led to inconsistent payment decisions and requests for additional documentation on what appears to be an arbitrary basis. This lack of firm DMERC direction has led an industry watchdog group, the Power Mobility Coalition, to lobby CMS for greater claim adjudication consistency.

So, what do you need to obtain to stay compliant with Medicare regulations and still have your claims paid? Well, first you'll need a 100% complete and legal CMN demonstrating the medical justification for the chair. In theory, this plus a properly completed HCFA-1500 or electronic claim for a Medicare Part B beneficiary is all you'll need to have your claim adjudicated in your favor. In practice, you'll need both of these items plus additional documentation just in case you are asked to produce it in a pre- or post-payment audit. This documentation should consist of the following:

4 The chair's manufacturer name, model and serial number (can be on the manufacturer's order form).

4 Documentation such as progress notes from a physician, PT or OT describing the patient's capabilities and limitations preventing the use of a manual chair or POV to include extremity strength, trunk stability, ambulation ability, cognitive and visual abilities and how the chair will benefit the patient.

This additional information will be required in an audit situation and if you cannot produce it, you may be facing a denial or overpayment situation. Remember what your grandmother used to tell you, "An ounce of prevention is worth a pound of cure." Enough said.

Bruce Brothis is President of Centralized Billing & Intake, Ltd. Reach him at (800) 396-9910.

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