Power Wheelchairs: What the Physician Must Do to Ensure Medicare Coverage

http://www.gotomeeting.com/fec/web_conferencing_comparisonCMS Finds High Incidence of Improper Payments for Power Wheelchair Claims

Based on the findings of the Comprehensive Error Rate Testing (CERT) program reviews of power wheelchair claims, the Centers for Medicare & Medicaid Services (CMS) conducted a special study of power wheelchair claims.

The power wheelchair categories studied include:

  • Group 1: Standard, portable, sling/solid seat/back, capacity up to 300 lbs. (K0813)
  • Group 2: Standard, portable, captain’s chair, capacity up to 300 lbs. (K0821)
  • Group 2: Standard, sling/solid seat/back, capacity up to 300 lbs. (K0822)
  • Group 2: Standard, captain’s chair, capacity up to 300 lbs. (K0823)
  • Group 2: Heavy duty, sling/solid seat/back, capacity 301 to 450 lbs. (K0824)
  • Group 2: Heavy duty, captain’s chair, capacity 301 to 450 lbs. (K0825)
  • Group 3: Heavy duty, sling/solid seat back, capacity 301 to 450 lbs. (K0850)
  • Group 3: Very heavy duty, single power option, sling/solid seat/ back, capacity 301 to 450 lbs. (K0861)

What Power Wheelchair Claim Problems Were Found in the Study?

Insufficient Documentation

The majority of power wheelchair errors were due to insufficient documentation errors. Insufficient documentation errors occur when the medical documentation submitted is inadequate to support payment for the services billed. In other words, the medical reviewers could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims are also placed into this category when a specific documentation element that is required as a condition of payment is missing. This may include a physician signature on an order, or a form that is required to be completed in its entirety. EXAMPLE: Mrs. Smith’s medical record showed that she had a physical condition that led to leg weakness and falls at home. However, the face-to-face examination did not address why her mobility limitations could not be sufficiently and safely resolved by the use of an appropriately fitted cane or walker. This claim was scored as an improper payment due to an insufficient documentation error.

Medical Necessity

A small proportion of claims in this special study were categorized as medical necessity errors. Medical necessity errors occur when the medical reviewers receive adequate documentation from the medical records submitted to make an informed decision that the services billed were not medically necessary based upon Medicare coverage policies. A common reason for medical necessity errors was that the face-to-face examination did not support that the beneficiary’s condition required the use of a power wheelchair, such as when they were able to safely ambulate with the use of a walker. EXAMPLE: Mr. Jones’ medical record showed that he had a physical condition that led to leg weakness and falls at home. However, the face-to-face examination mentioned that she was safely ambulating around the house with the use of an appropriately fitted walker, but that she wanted the power wheelchair so that she could travel around the neighborhood. This claim was scored as a medical necessity error.

There is currently a prior authorization pilot underway in seven states where CMS will review the patient’s medical record before a device is shipped to ensure they need a wheelchair. The pilot, which started September 1, 2012, is ongoing in California, Illinois, Michigan, New York, North Carolina, Florida, and Texas.

Federal health officials noted that nearly 80 percent of the power wheelchair claims submitted to Medicare don’t meet program requirements. Note that this may mean that the protocol was not followed, as opposed to the patient not being eligible based on medical necessity. That error rate represents more than $492 million in improper payments annually. The cost for the devices ranges from $1,500 for scooters to $3,600 for more complex power wheelchairs over the course of the rental period. Medicare payment can only be made on a rental basis for standard power wheelchairs furnished on or after January 1, 2011.

What are the Requirements for Medicare Coverage for Power Wheelchairs?

Medicare provides coverage for wheelchairs and scooters under its Part B Durable Medical Equipment (DME) benefit. Here are the requirements for Medicare payment:

  • The physician or treating practitioner must conduct a face-to face history and physical examination (the in-person visit and mobility evaluation together are often referred to as the “face-to-face examination”) of the beneficiary and write a prescription for the item.  The prescription must include the following seven items:
    1. Beneficiary’s name
    2. Description of the item that is ordered. This may be general – e.g., “power operated vehicle”, “power wheelchair”, or “power mobility device” – or may be more specific.
    3. Date of completion of the face-to-face examination
    4. Pertinent diagnoses/conditions that relate to the need for the POV or power wheelchair
    5. Length of need
    6. Physician’s signature
    7. Date of physician signature
  • The beneficiary must show the provider why they cannot use a cane, walker or manually operated wheelchair to effectively perform Mobility-Related Activities of Daily Living (MRADLs) in the home. MRADLs include feeding, dressing, grooming, bathing, and toileting.
  •  The beneficiary must be able to safely and effectively use the power wheelchair in the home.
  • The prescription and medical records documenting the in-person visit and evaluation must be sent to the equipment supplier within 45 days after the completion of the evaluation.
  • After the supplier receives the provider’s order and the face-to-face information, they will prepare a detailed product description that describes the item(s) being provided including all options and accessories. The provider should review it and, if in agreement with what is being provided, sign, date and return it to the supplier. If not in agreement, the provider should contact the supplier to clarify what you want the beneficiary to receive.

Suppliers must meet all documentation requirements included in the power wheelchair Local Coverage Determinations (LCD) issued by the DME Medicare Administrative Contractors (MACs) in order to receive Medicare payment for a power wheelchair. The LCD requires that suppliers maintain a variety of documents that support the beneficiary’s need for, and the appropriateness of, the provided power wheelchair.

Documentation of the Visit for Your Medical Record (Paper or Electronic) for PWCs

The face-to-face examination must be relevant to the patient’s mobility needs and include the following elements:

    • History of present condition and relevant past medical history, including symptoms that limit ambulation,
    • Diagnoses that are responsible for symptoms,
    • Medications or other treatment for symptoms,
    • Progression of ambulation difficulty over time,
    • Other diagnoses that may relate to ambulatory problems,
    • Distance patient can walk without stopping,
    • Pace of ambulation,
    • Ambulatory assistance currently used,
    • Change in condition that now requires a PMD
    • Description of home setting and ability to perform MRADLs in the home.
    • Physical examination relevant to mobility needs, including height and weight,
    • Trunk stability (sitting/standing),
    • Cardiopulmonary examination,
    • Arm and leg strength and range of motion; and
    • Neurological examination, including gait, balance and coordination.

Examples of vague or subjective descriptions of the patient’s mobility limitations include:

  • upper extremity weakness” “poor endurance”
  •  “gait instability”
  •  “weakness”
  •  “abnormality of gait”
  •  “difficulty walking”
  •  “SOB on exertion”
  •  “pain”
  •  “fatigue”
  •  “deconditioned”

Acronyms for power wheelchairs:

PWC – power wheelchairs

POV – power-operated vehicle (scooter)

PMD – power mobility device (includes PWCs and POVs)

MAE – mobility assistive equipment (includes the continuum of technology from canes to power wheelchairs)

How to Bill for Examination & Mobility Evaluation for a Power Wheelchair

  • In the outpatient setting, bill the appropriate level of service from the codes 99201 – 99205 for new patients and from the codes 99211 – 99215 for established patients.
  • Bill the G0327 for service required to establish and document the need for a power mobility device (the national payment amount for this code is $9.81)
  • The diagnosis for the E/M code and the G0327 should be what condition creates medical necessity for the power wheelchair.

Robert Anthony from CMS Takes Questions on Stage One Meaningful Use in PhysiciansPractice Webinar

Today, PhysiciansPractice sponsored a webinar with CMS’s Robert Anthony on the topic of “Meaningful Use Stage 1.” Robert Anthony is a Health Insurance Specialist in the Office of E-Health Standards and Services (OESS) at the Centers for Medicare & Medicaid Services (CMS), where he focuses on the EHR Incentive Programs. Robert had a very pleasant voice to listen to, and he gets my vote for the best CMS Employee Speaker that I’ve heard!

I was not familiar with the OESS before, so I looked it up and found out what they do: Provide the overall leadership for and coordinate the implementation of Title IV of the HITECH Act. (Title IV = Medicare and Medicaid Health Information Technology)

Robert briefly reviewed what has happened to date with the EHR Incentive Program and the terms of the Medicare and Medicaid programs. The three main differences in the two programs are:

  1. The types of providers that are eligible for each program – information here.
  2. The volume of each type of patient needed to participate: no volume needed to participate in the Medicare program and 30% Medicaid patients for all eligible practitioners except pediatricians who only need 20% Medicaid patients.
  3. The tasks in year one in which the certified EHR is adopted. For Medicaid the practice only needs to attest that they have adopted, implemented or upgraded an EHR. In year one for Medicare the practice needs to attest to meaningful use for 90 days, which means data is collected and input into the attestation system.

The majority of the webinar was devoted to FAQs (my favorite part of any CMS-related education session!)


Q: Can entities participate in the Medicare EHR Demonstration Project, and the Medicare or Medicaid EHR Incentive programs too?

A: Yes. The demonstration projects are about to be sunsetted (completed.)

Q: What information must be provided to patients to meet the requirement for a clinical summary at the end of each visit?

A: If system is certified, it will automatically provide the appropriate information for the clinical summary, which includes the patient’s problem list, medication list, medication allergy list, and diagnostic test results.

Robert suggested looking at the answer online at the CMS FAQ which I posted below:

In our final rule, we defined “clinical summary” as: an after-visit summary that provides a patient with relevant and actionable information and instructions containing, but not limited to, the patient name, provider’s office contact information, date and location of visit, an updated medication list, updated vitals, reason(s) for visit, procedures and other instructions based on clinical discussions that took place during the office visit, any updates to a problem list, immunizations or medications administered during visit, summary of topics covered/considered during visit, time and location of next appointment/testing if scheduled, or a recommended appointment time if not scheduled, list of other appointments and tests that the patient needs to schedule with contact information, recommended patient decision aids, laboratory and other diagnostic test orders, test/laboratory results (if received before 24 hours after visit), and symptoms.

The EP must include all of the above that can be populated into the clinical summary by certified EHR technology. If the EP’s certified EHR technology cannot populate all of the above fields, then at a minimum the EP must provide in a clinical summary the data elements for which all EHR technology is certified for the purposes of this program (according to §170.304(h)):

  • Problem List
  • Diagnostic Test Results
  • Medication List
  • Medication Allergy List

Q: How and when are incentive payments made?

A: After the online attestation is made (attestation thresholds must be attained), provider information is verified, then in 6 to 8 weeks a payment is generated. Payments are made in whatever way the entity typically gets CMS payments.

Q: What if patients do not routinely receive prescriptions during an office visit? How can the threshold be met? (Referring to computerized provider order entry (CPOE) for medication orders.)

A: For attestation, practices need to do this for 30% or more of all unique patients with at least one medication in their medication list. Note that patients with no medications in their medication list are excluded, so CMS believes this core initiative is realistic.

Q: For the Medicaid program, do you count the patient visit or the number of services (e.g. patient visit plus two tests equals three patient ticks) during the visit?

A: This question needs follow-up and if you send an email to editor@physicianspractice.com, they will be sent to CMS for the answer. Here is additional information from the CMS FAQ:

When calculating Medicaid patient volume or needy patient volume for the Medicaid EHR Incentive Program, are eligible professionals (EPs) required to use visits, or unique patients?

There are multiple definitions of encounter in terms of how it applies to the various requirements for patient volume.  Generally stated, a patient encounter is any one day where Medicaid paid for all or part of the service or Medicaid paid the co-pays, cost-sharing, or premiums for the service.  The requirements differ for EPs and hospitals.  In general, the same concept applies to needy individuals.  Please contact your State Medicaid agency for more information on which types of encounters qualify as Medicaid/needy individual patient volume.

Q: We are a new practice and plan on getting an EMR in the next 3 months. Can you walk me through the time lines?

A: If you haven’t chosen an EMR yet, your first year in either program will probably be 2012. In the first year of Medicare participation, you will need to use the EMR meaningfully for 90 days during calendar year 2012, and you have up to 60 days after the close of the calendar year to attest to your use. In the first year of Medicaid participation, you will need to adopt (acquire, install), implement (commence utilization of EHR such as train, data entry), or upgrade (expand) a certified EHR and attest to your activity at any time during the calendar year.

Q: What validation or oversight will CMS provide for the attestation process?

A: Before any payment is made, checks of provider eligibility and information will be done. Keep in mind that attestation is a legal process. Random audits will be put in place in the near future.

Q: Should a practice register if we don’t know which program we are going to use?

A: You can register at any time, and you can change from one program to the other prior to attesting, so you can register for one program and change before you begin the attestation.

Q: If your first year of attestation is in 2012, can you get the full 44K over the course of the program?

A: Yes.

Q: Can you verify if Physician Assistants are eligible for one of the programs?

A: Physician Assistants (PAs) are only eligible under the Medicaid program and must be the lead provider for a Federally Qualified Health Center (FQHC) or Rural Health Clinic (RHC) to qualify.

Q: Does a radiology practice have to provide a clinical summary for patients?

A: No practice type is excluded from clinical summary mandate. CMS has not heard of any practice type having a problem with this so far. Remember, to achieve meaningful use, you must provide clinical summaries to patients for more than 50 percent of office visits within three business days. Exclusion: Any EP who has no office visits during the period of EHR reporting.

Q: Is the problem list supposed to be related to the chief compliant of the office visit?

A: Not necessarily. Practices are required to maintain an up-to-date problem list of current and active diagnoses based on ICD-9-CM or SNOMED CT (Systematized Nomenclature of Medicine – Clinical Terms) codes. To comply, at least 80 percent of all unique patients seen by eligible providers must have at least one entry (or an indication of none) recorded as structured data.

Q: What if questions were not able to be answered during the webinar?

A: Please e-mail Physicians Practice and we’ll get your answers from CMS. This could take several days, so please be patient. We will post your answers and all post-webinar questions at http://www.physicianspractice.com and notify you via e-mail as well.


A great list of additional resources were provided by Robert Anthony and Physicians Practice:

Resources from CMS

Resources from PhysiciansPractice.com


Other Posts I have written on this topic:

Step by Step Directions for Getting the EHR Incentive Money: My Notes From Last Week’s CMS Call

CMS Holds National Provider Calls for the Medicare EHR Incentive Program and EHR Attestation Q & A

Digging Into the Details of “Certified EMR” & Tips For Buying an EMR

How Do You Get That Stimulus Money for Using an Electronic Medical Record? (You Register!)

How My Practice Knew We Were Ready for EMR

10 Ways to Get More Out of Your PM, EMR or Any Medical Software