As is true with many high end items, the Centers for Medicare and Medicaid Services has focused much of its attention and scrutiny on reimbursement of power wheelchairs during the past several years. The K0011 wheelchair — defined as a “standard-weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control and braking” — is no exception.

When CMS agreed in 2001 to include wheelchairs in the prior authorization process, the agency became selective in the chairs it chose. Specifically, CMS only required an Advance Determination of Medicare Coverage for K0011 wheelchairs that have a power tilt and/or power recline seating system, or a non-joystick control device such as a head, sip-and-puff or switch control.

In addition to the fact that the ADMC includes limited types of chairs, another problem exists when the wheelchair needs a repair or replacement component, according to Reid Bellis of the Folsom, Calif.-based Custom Rehab Network. The ADMC is useful only when the chair is initially ordered, and unfortunately for providers, much of the reimbursement woes revolve around repair items, he says.

With or without the ADMC, the K0011 wheelchair requires substantial documentation to be reimbursed. The basic elements required for coverage include:

• Diagnosis. Simply because someone is plagued with Parkinson's disease or multiple sclerosis does not mean that he or she is a candidate for a power wheelchair, especially a K0011. The diagnosis must show that the patient is unable to operate a manual wheelchair due to a severe neurological or muscular condition of both arms and legs, such as a spinal cord injury, advanced multiple sclerosis, or advanced or progressive amyotrophic lateral sclerosis.

• Proof of functional impairment. Patient impairment must involve paralysis or such severe weakness of the arms and legs that the patient is unable to propel a manual wheelchair in the home. Be aware that respiratory conditions such as chronic obstructive pulmonary disease and emphysema do not typically qualify the patient for a power wheelchair because COPD patients usually can operate a manual wheelchair.

• Descriptive information about the wheelchair. Be sure to include the manufacturer and the model or number of the wheelchair that was ordered and delivered to the patient.

• Purchase option letter. Medicare needs to know if the patient elected the purchase option in the first month. The “BP” modifier indicates that the patient elected the purchase option. The letter should stay in the patient's file for audit purposes.

• Physician information. Besides the certificate of medical necessity for power wheelchairs, you should obtain copies of the progress notes from the treating physician's medical chart for the patient. These notes should relate to the diagnoses listed on the CMN, address the functional levels that justify the need for the power wheelchair, and indicate that the chair will be used in the home. It is important that the doctor include a note about ordering the wheelchair, which includes the reasons why the chair was ordered. The progress notes also should include the patient's functional limitations as observed on different dates, as well as the patient's ambulatory status and the medical conditions causing its impairment.

In addition to these basic coverage elements, a K0011 power wheelchair requires a detailed evaluation of the patient by the physician, physiatrist, licensed physical therapist or certified occupational therapist. According to CMS guidelines, the written evaluation should include:

• the condition necessitating use of a power wheelchair;

• the date of onset of this condition;

• the progression of the condition and the prognosis;

• a semi-quantitative assessment of strength in the extremities;

• the presence or absence of increased muscle tone or spasms; trunk stability and sitting posture;

• a quantification of the patient's ability to ambulate and what assistance (e.g., cane, walker, other person, etc.) is needed for this (if applicable);

• an assessment of the patient's ability to transfer from bed or chair to wheelchair (including the ability to stand and pivot);

• an endurance assessment;

• an assessment of the patient's cognitive abilities;

• an assessment of the patient's visual impairments; and

• a description of the patient's current wheelchair (if applicable), age of the wheelchair and why it is being replaced.

What if the patient is using another wheelchair but now requires a K0011 chair because of a worsened condition such as a progressive disease like Parkinson's Disease or ALS?

When this happens, document the nature of the medical condition, and how the patient's functional level has changed to warrant the need for new equipment.

In addition to CMS' list of requirements for the wheelchair evaluation, Violeta Arnobit, chief executive officer of Honolulu-based Ace Medical suggests conducting a more detailed background check, including, but not limited to, the following:

1. Medical profile, including the patient's

   • current medications,
   • nutrition,
   • respiratory function,
   • cardiovascular function,
   • neurological status,
   • orthopedic status,
   • range of motion,
   • previous surgeries,
   • hospitalization history, and
   • any additional information relating to the functional limitation.

2. Home environment, including the patient's

   • accessibility on equipment, and
   • mode of transportation.

3. Questions about additional functional concerns, including

   • Can the patient feed himself or herself?
   • Can the patient communicate verbally or non-verbally?
   • Why does the current mode of mobility not meet the patient's needs?
   • What progressive medical or functional changes is the patient experiencing?
   • Is there a skin condition or a history of recurring skin breakdown?
   • Is the patient currently using a wheelchair cushion? If so, what type?
   • How long does the patient spend in the chair?
   • If the patient does not get pressure relief, does he or she need a tilt system?

4. Wheelchair recommendation, including

   • type of mobility base;
   • special accessories and options based on functional limitation;
   • documentation on each accessory to show patient's needs; and
   • a list of which options on the K0011 are not available on the K0012 or K0010 chairs.

5. Goals and objectives for the patient, including

   • improved posture;
   • pressure relief;
   • improved functional level;
   • improved seating and positioning; and
   • accommodation of the patient's deformity.

“Focus on the patient's functional limitations and how the K0011 chair will make a difference in the patient's activities of daily living,” Arnobit says. “Then, explain why the current chair cannot meet the patient's present needs.”

While the documentation you gather helps to build your case for the chair, a simple mistake still can prove fatal in the end. For instance, if the therapist or physician fails to sign and date the evaluation, you will have difficulty proving that the evaluation was furnished. Also, according to Bellis, miscellaneous codes should include “the description, list pricing, manufacturer, model number or serial number.” If you are unsure of the code, call the Statistical Analysis DMERC for coding verification — and be sure to document with whom you spoke and the time and date of your conversation.

According to Claudia Amortegui, a former Medicare employee and director of Sunrise Consulting in Charlotte, N.C., providers should “document trial and failure of all types of manual wheelchairs, show why the K0010 or K0012 chair won't suffice, triple check that the [patient] does not have any other same or similar equipment and be sure that the PT or OT is experienced in seating and positioning.”

Arnobit agrees with Amortegui that the PT or OT must exhibit “good ethics and sound judgment to make a professional and qualified assessment.” Additionally, she submits her documentation to a qualified rehab consultant for a pre-billing assessment, a service that Sunrise Consulting also offers. This type of service can be a security blanket for people who feel exposed when submitting an expensive claim to Medicare for an item that does not have an ADMC. Additionally, a quality control check from an unbiased, experienced source can prove invaluable.

Whether you employ the ADMC, use a pre-adjudication service or take seriously the extra documentation requirements, realize that Medicare reimburses K0011 wheelchairs every day. With patience, perseverance, and complete and accurate documentation, you can get reimbursed.