CMS simplifies replacement wheelchair rules 

YARMOUTH, Maine – The DME MACs in June indicated that prior authorizations for identical replacement power mobility devices after the five-year reasonable useful lifetime (RUL) only require a detailed written order prior to delivery (WOPD) and documentation of continued medical need. 

Based on a new clarification, providers no longer have to submit a new face-to-face evaluation or documentation of medical need for the item ordered, as medical necessity has already been established and the item was previously paid for by Medicare. 

“Overall, this is huge,” said Dan Fedor, director of reimbursement and education for U.S. Rehab. “They don’t need to make sure everything is justified all over again. It takes the burden off the therapist, the clinician, the physician and the supplier, and it expedites delivery.” 

What’s the impact? 

Stakeholders estimate about 20% of users who need a new wheelchair after the five-year RUL will need an identical wheelchair. 

“Also, if they’re staying in, for example, a K0861, the manufacturer for the chair doesn’t even have to be the same,” said Martin Szmal, owner of the Mobility Consultants. “It’s just as long as it’s the same code.” 

Why is the change not exactly a carte blanche?  

While it’s technically OK to forgo the evaluation for an identical replacement wheelchair, Fedor and Szmal both say it’s probably a good idea to reassess the patient’s need after five years to ensure the wheelchair is still appropriate. 

“Especially for complex rehab, you probably want to make sure these products are still appropriate for the beneficiary,” Fedor said. “The ATP, for some cases, can determine if they should be seen by a therapist for another evaluation.” 

On the other hand, if the physician signs off on the order, shouldn’t providers be able to assume the patient has been seen by a physician who is attesting that the original equipment is still medically necessary? Technically, yes, Fedor says. 

Are there any gray areas? 

There are still questions around what happens if, say, a patient now qualifies for a power seat elevation system, which doesn’t require prior authorization. Can the therapist just evaluate the beneficiary for the seat elevation and, if coverage criteria are met, provide that item in addition to the identical items from the original wheelchair? 

“Yes, just that one item, as medical necessity has already been established for the original codes provided,” Fedor said. “So, for seat elevation, a wheelchair evaluation is required and an order. A face to face is not required.”  

Dan Fedor, as well as Noel Neil of ACU-Serve, Jim Stephenson of Permobil and Ginger Walls of Permobill, will host a webinar, PMD Replacement (before and after) the 5 Year RUL, on Thursday July 24 at 10 a.m. CT. Register here.