The Answer to Getting Power Wheelchair Claims Paid Properly

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  • September 11, 2015
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The Answer to Getting Power Wheelchair Claims Paid Properly

According to the Centers for Medicare & Medicaid Services (CMS), the improper payment rate for power mobility devices (PMDs) in 2013 was 81.8 percent, which amounts to approximately $329 million in erroneous payments made under Original Medicare. Documentation and medical necessity errors were behind most of these improper payments.
CMS recommends that providers and suppliers work together to help avoid improper payments. There are five basic components for success:

  1. The physician or non-physician professional (NPP) conducts a face-to-face exam, documenting the patient’s present condition(s) and past medical history relevant to mobility needs.
  2. The physician/NPP forwards the documentation and seven-element order to the PMD supplier within 45 days of completing the face-to-face examination.
  3. The supplier sends the physician/NPP a detailed product description and the physician reviews, signs, and dates the detailed product description before returning it to the supplier.
  4. Either the provider or supplier conducts a home assessment.
  5. The supplier delivers the PMD to the patient within 120 days of the patient’s face-to-face exam and forwards proof of delivery to the physician/NPP.

Remember that there are two programs that may affect payment, regardless of whether you satisfy all the usual requirements:

  1. The Medicare Fee-For-Service Prior Authorization of PMD demonstration; and the
  2. Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Competitive Bidding Program.

For further guidance, refer to the Medicare Learning Network fact sheet, “Power Mobility Devices (PMDs): Complying with Documentation & Coverage Requirements.”
See, also, MLN Matters® Number SE1112 for guidance, examples, tips, and a sample checklist for the PMD exam.

Renee Dustman
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Renee Dustman, BS, AAPC MACRA Proficient, is managing editor - content & editorial at AAPC. She holds a Bachelor of Science degree in Media Communications - Journalism. Renee has more than 30 years' experience in journalistic reporting, print production, graphic design, and content management. Follow her on Twitter @dustman_aapc.

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  1. rjg says:

    Everything Renee wrote here is correct but there is so much more to getting any PMD covered. There is a full page checklist most suppliers use to check against the documentation that the ordering providers must include with his/her order. Often the patient is also seen by Physical Therapy. The are often able to document the detailed mobility deficits as well as the objective documentation needed in order for the supplier to meet the requirements for a Medicare order.