In order for an Advanced Determination of Medicare Coverage to be accepted for a wheelchair after Aug. 10, 2006, the following demographic items must
by Jane Bunch
Sunday, October 1, 2006

In order for an Advanced Determination of Medicare Coverage to be accepted for a wheelchair after Aug. 10, 2006, the following demographic items must be listed on the first page (if all of them are not, it will be rejected):

  • Beneficiary information: name, HICN, address, date of birth

  • Place of service

  • ICD-9 diagnosis code (a narrative description is not acceptable)

  • Supplier information: name, NSC number, address and phone number (I recommend you include your NPI number as well, though it is not required at this time.)

  • Physician information: name, UPIN, address and phone number

If your ADMC is for a power wheelchair, the following items must be included:

  1. The order the supplier received within 45 days of the face-to-face evaluation, which must include the following:

    • Beneficiary name

    • General or specific description of the item (“power wheelchair” or “power mobility device” is acceptable, but I recommend being more specific.)

    • Date of the face-to-face examination (this will be the last date seen if there were multiple visits)

    • The conditions and diagnosis only that show why there is a need for a power wheelchair

    • The length of need

    • Physician's signature and date of signature

    • The order must have a date stamp or some other type of equivalent means of showing when the provider received the order from the physician.

  2. A detailed product description of the information in the written order that lists the specific wheelchair base provided and each accessory or option that will be separately billed by the provider. Each item must have a specific HCPC code associated with it. The provider can enter this information and it must be signed and dated by the physician, although the physician signature does not have to be within the 45-day time limit of the face-to-face examination.

    As of Aug. 24, 2006 a supplier's charge and fee schedule amount must be listed for each item as well. If an item does not have a fee schedule amount you are instructed to enter “not applicable.”

  3. A copy of the face-to-face exam (and licensed certified medical professional if applicable). The copy must have a date stamp or equivalent to show when the supplier received the order from the physician. If the LCMP report is to be considered part of the face-to-face exam, a letter must be received from the LCMP attesting that he or she has no financial relationship with the provider.

  4. A home assessment that shows the ordered wheelchair will assist the beneficiary to perform activities of daily living in the home.

If your ADMC is for a manual wheelchair, as the provider you will need to include the following items:

  • A detailed written order that lists the specific wheelchair base provided and each accessory or option that will be separately billed for by the provider. Each item must have a specific HCPC code associated with it. The provider can enter this information and it must be signed and dated by the physician;

  • Patient's medical record information that substantiates the coverage criteria, as defined in the medical policy, has been met; and

  • A home assessment that shows the ordered wheelchair will assist with ADLs in the home and the beneficiary or caregiver is able to use the ordered wheelchair.

Additionally, you will want to provide the following information on all wheelchair ADMCs:

  • Supporting information that explains the medical necessity of any options or accessories.

  • Patient's height and weight (on the first page of the ADMC request); and

  • Make, manufacturer, model (product name) and width of wheelchair cushions (Make sure the HCPC code is the one specified by SADMERC.)

If you submit an ADMC and you receive an affirmative determination on the base but some of the accessories are denied, you cannot resubmit another ADMC for determination of the denied items. But if you are denied at the time of claim submission, you may still appeal the decision and provide additional documentation during the appeal.

Jane Bunch is vice president, HME consulting, for Atlanta-based CareCentric. A reimbursement specialist, Bunch delivers educational seminars worldwide, helps develop corporate compliance plans and serves as a consultant for fraud and abuse cases. She can be reached at 678/264-4495 or via e-mail at jane.bunch@carecentric.com.