Funding 2012

New Codes, A New NCB Round & Hello, Demo!

Thanks to the impending arrival of the second round of Medicare’s national competitive bidding (NCB) program, funding figured to remain a critical industry topic for 2012.

Then came the announcement, in November, of demonstration projects that were scheduled, at press time, to begin Jan. 1, 2012.

Demonstration Project 101

The Centers for Medicare & Medicaid Services (CMS) announced that claims for scooters and most types of power wheelchairs for Medicare beneficiaries in seven states will be subject to prepayment and prior authorization scrutiny.

The seven states — California, Florida, Illinois, Michigan, New York, North Carolina and Texas — were chosen for the demonstration projects because of “high populations of fraud- and error-prone providers,” according to a news announcement from CMS on Nov. 15.

Claudia Amortegui, president of The Orion Group and an expert on complex rehab technology and mobility reimbursement issues, said those seven states represented 43 percent of power mobility device (PMD) expenditures in 2010.

Amortegui added that 325,000 PMD claims are expected to be aff ected during the three-year life of the demonstration project.

At press time and according to, most types of PMD will be subject to prepayment review and prior authorization:

  • Power-operated vehicles (aka, scooters): HCPCS codes K0800-K0805 and K0809-K0812.
  • Standard power chairs: HCPCS codes K0813-K0829.
  • Group 2 complex rehab power chairs: HCPCS codes K0835-K0843.
  • Group 3 complex rehab power chairs without power options: HCPCS codes K0848-K0855.
  • Pediatric and Group 4 power chairs: HCPCS codes K0887-K0891.
  • Miscellaneous power wheelchairs with HCPCS code K0898.

Group 3 power chairs with powered seating options — aka, HCPCS codes K0856-K0864 — are not included in the prepayment review or prior authorization requirements.

The demonstration project will roll out in two distinct phases, according to CMS’s initial announcement.

CMS described the first phase as lasting “the first three to nine months” and said this period would consist of Medicare Administrative Contractors conducting prepayment reviews.

Amortegui said CMS has indicated it’s expecting 79,500 claims to be impacted in year 1, and that the prepayment reviews will be carried out by DME MAC staffers.

The second phase, defined as lasting “the remainder of this three-year demonstration,” will consist of prior authorization, described by CMS as “a tool utilized by private-sector health care payors to prevent improper payments and deter fraudulent provision of items or services.”

Alluding to the obvious front-end wait that prior authorizations will cause, Amortegui said CMS expected to be able to provide responses within 10 business days, or 30 days for resubmitted requests.

She also noted that the “seven states” definition for the demonstration project refers to where the Medicare beneficiary lives, not where the DME supplier’s or complex rehab supplier’s office is. For instance, if the supplier is located in Nevada, but files a claim for a K0823 power chair for a client who lives right across the state border in California, that claim would be subject to the demonstration project’s policies.

CMS said the goal of the demonstration projects would be to “strengthen Medicare by aiming at eliminating fraud, waste and abuse.”

Competitive Bidding: Round 2 Gets Under Way

The dust kicked up by the demonstration project announcement hadn’t yet settled when CMS released, on Nov. 30, the timeline for round 2 of its Medicare national competitive bidding program.

Registration for user IDs and passwords began less than a week later, on Dec. 5, and authorized officials were “strongly encouraged” to register no later than Dec. 22.

CMS was similarly encouraging backup authorized officials to register by Jan. 12.

Other key dates, according to CMS (

  • Jan. 30, 2012: CMS opens 60-day bid window for round 2 and national mail-order competitions.
  • Feb. 9, 2012: Registration closes.
  • Feb. 29, 2012: Covered Document Review Date for bidders to submit financial documents.
  • March 30, 2012: 60-day bid window closes.
  • Fall 2012: CMS announces single-payment amounts and begins the contracting process.
  • Spring 2013: CMS announces contract suppliers and begins contract supplier education campaign. CMS begins supplier, referral agent and beneficiary education campaign.
  • July 1, 2013: Implementation of competitive bidding round 2 and national mail-order competition contracts and prices.

In her Dec. 2 Mobility Management Webinar titled Are You Ready? 2012, It’s Around the Corner, Amortegui said she was advising her reimbursement clients to start the registration process immediately if they intended to bid or thought they might want to bid.

And in a bit of good news, Amortegui added that ultralightweight manual chairs (HCPCS code K0005) will not be among the products up for bidding in round 2. Neither will products in the K0009 code; E1161 code; and complex rehab power chairs, defined Group 3 chairs and Group 2 chairs with single or multiple powered options.

What will be included, Amortegui said:

  • All POVs (scooters).
  • Transport chairs up to HCPCS code K0007.
  • All Group 1 power wheelchairs.
  • All Group 2 power wheelchairs with no powered options.

In addition, Amortegui noted, while many wheelchair cushions and backs are considered complex rehab technology products by clinicians and providers in the industry — and complex rehab technology is excluded from the competitive bidding program — cushions and backs will be included in the bidding process if in fact they are an accessory for a wheelchair or scooter that is included in the program.

So for instance, a seat cushion with HCPCS code E2624 — defined as a skin protection & positioning cushion with a width less than 22” and with any depth measurement — would be subject to competitive bidding if it’s used on a power chair coded K0823. That’s because the K0823 code, defined as a Group 2 standard power chair with captain’s seating and a patient weight capacity up to and including 300 lbs., is being competitively bid.

Amortegui pointed out that 91 metropolitan statistical areas (MSAs) are included in round 2 bidding, meaning 100 competitive bidding areas (CBAs) are involved because Chicago, Los Angeles and New York include multiple CBAs.

And despite multiple ongoing industry efforts to alter or halt the competitive bidding program, Amortegui said she was advising her clients to plan and carry on as if round 2 will indeed go through.

“Don’t think we can just will it to disappear,” she said.

New HCPCS Codes for 2012

As always, a new year means changes in some HCPCS codes. Amortegui said there would be no discontinued codes for 2012, no changes in code verbiage, and no new modifiers.

But there are some new codes, Amortegui said, eff ective for dates of service starting Jan. 1, 2012:

  • E0988: Manual wheelchair accessory, lever-activated wheel drive, pair.

  • E2358: Power wheelchair accessory, Group 34 nonsealed lead acid battery, each.

  • E2359: Power wheelchair accessory, Group 34 sealed lead acid battery, each.

  • E2626: Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable.

  • E2627: Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, adjustable Rancho type.

  • E2628: Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, reclining.

  • E2629: Wheelchair accessory, shoulder elbow, mobile arm support attached to wheelchair, balanced, friction arm support (friction dampening to proximal and distal joints).

  • E2630: Wheelchair accessory, shoulder elbow, mobile arm support, monosuspension arm and hand support, overhead elbow forearm hand sling support, yoke-type suspension support.

  • E2631: Wheelchair accessory, addition to mobile arm support, elevating proximal arm.

  • E2632: Wheelchair accessory, addition to mobile arm support, off set or lateral rocker arm with elastic balance control.

  • E2633: Wheelchair accessory, addition to mobile arm support, supinator.

Succeeding in 2012: Claudia’s Tips

Ongoing audits of several kinds, combined with new power wheelchair demonstration projects and round 2 of competitive bidding, are sure to challenge providers’ workflows and cashflows. With that in mind, Amortegui offered several tips for dealing with the issues sure to arise.

  • For pre- and post-pay audits:
    Have a detailed plan for how to handle them. Start with being sure someone is checking incoming mail carefully for audit notices, so the process of collecting and sending additional documentation can be started promptly.

    Amortegui also suggested having a “key” reviewer to oversee and keep control of the audit process; using the correct forms; sending additional documentation in at once; responding only once to each request; and refraining from combining your responses.

  • For Dear Physician letters:
    While they are supposed to educate physicians on, for instance, their role in the DME documentation chain, these letters are often lengthy…which means physicians may not completely read them, or perhaps not read them at all. Amortegui suggests highlighting the most important parts of these letters before sending them, to encourage physicians to at least read critical portions. A bonus of using these letters, Amortegui points out: They prove that providers are asking for documentation because of specific CMS policy…not just to be arbitrary. The Dear Physician letters can be found on the DME MAC Web sites.

  • Your clients are being judged by what’s on the documentation:
    Terrific providers tend to have long-term relationships with their clients, so you may have fitted John Smith for his last three wheelchairs. You know about his surgeries, how his condition has progressed over the years, and that he’ll always choose blue for his power chair color.

    But the people reviewing claims for Mr. Smith’s equipment know him solely from the documentation you provide. That’s how they make their judgments. Providing detailed descriptions will help them to see Mr. Smith the way you do.

  • Training, training, training:
    Now more than ever, staying updated on new policies and processes is critical. Amortegui suggests staging your own audits to assess the job you’re doing before CMS’s contractors do. And everyone needs to take care of the basics, such as proper intake to avoid same/similar denials, and paying attention to details so claims aren’t rejected on a technicality.

This article originally appeared in the January 2012 issue of Mobility Management.

In Support of Upper-Extremity Positioning