The Secret of Successful Billing

If you've been tuned in to government action regarding wheelchairs lately, you know that the Centers for Medicare and Medicaid Services issued a statement in December headlined: “Medicare opens National Coverage Determination (NCD) to make sure beneficiaries who need wheelchairs get them.”

So what does this mean to your business and how you bill for wheelchairs? A little history first:

On the original Certificate of Medical Necessity (CMN) that came out in 1993, question No. 4 asked: “Would the patient be bed or chair confined without the use of a wheelchair?” This CMN was for motorized and manual wheelchair bases, as well as for wheelchair options.

On the current (December 2004) wheelchair CMN for both manual and power chairs, question No. 1 asks: “Does the patient require and use a wheelchair to move around in their residence?” This in itself has opened up the coverage so that those who are physically impaired, but not completely bed- bound, can receive a mobility device to assist in functional activities.

However, contrary to popular belief, this has long been the case. I worked at Medicare for almost four years, and I never denied a wheelchair base if the patient truly needed it. I worked very closely with all four DMERC regions, and we met quarterly. I never heard one clinician say that they denied (or would deny) a wheelchair if a patient could ambulate only two feet!

If a patient needs a mobility device, Medicare will pay for it. However, there has to be documentation as to need. Providers know that if a patient ambulates into their facility, a wheelchair is not covered. Physicians, physical and occupational therapists and others, however, quite often do not understand the rules. Too often, they think that it is OK to order a scooter because their patient, after seeing a TV commercial on scooters, calls and wants one.

To get a mobility device paid, a provider just needs to use common sense and evaluate patients for what they need — not what they want. Now, this does not mean that every patient has to have the cheapest, lowest-level mobility product available. It means that evaluation of all areas of need is important.

You must evaluate patients on the following criteria:

• What are their “functional” needs — that is, their activity level and their physical abilities or endurance?

• What kind of environment do they live in?

• What are their future needs for positioning? Is their disability related to a progressive disease, for example?