Bariatric Equipment: How Do I Get Paid?
There has been an increasing need for bariatric HME/DME products. In some instances, these products are being addressed, but not to the fullest extent that is really needed.
Take walkers, for example. Heavy-duty walkers have codes such as E0147. This is the code for a heavy-duty, multiple braking system, with variable wheel resistance. Such an item would be covered if the product itself met specific criteria and is listed on the SADMERC Web site. It must also be capable of supporting patients who weigh more than 350 lbs.
Meanwhile, a regular heavy-duty walker (E0148 or E0149) must be capable of supporting patients who weigh more than 300 lbs. These require a KX modifier.
You might ask, "Now what do I do if the patient weighs 500 lbs., but there is no walker that truly fits under one of these three heavy-duty codes, even though they can support a patient who weighs greater than 300 lbs.?"
This is the type of problem we face almost daily with the descriptors and coding now available in most DME categories. The allowable is set at a level to compare with most heavy-duty walkers, but would not even cover the cost for a truly obese patient.
To bill, use the E1399 code and hope you get paid for what you actually provided without having to fight for a year for adequate reimbursement. The best way to do this is to make sure that you state first that the patient does have the potential for ambulation (criterion required for a walker). Then you will need to give the name, make, model and MSRP of the item you are providing.
You will have to give a detailed description of the item, as well as why the other heavy-duty walkers will not meet the specific patient's needs. You will have to state what type of other walkers you looked at within the existing codes, the weight and measurements of the patient, and why the standard or heavy-duty item would not meet the needs as described. The manufacturer's information is always helpful, too.
I would suggest using an ABN, as well as explaining to the patient that Medicare may not think this item is medically necessary since they do have a code that states it is "heavy-duty" and supports weight greater than 300 lbs.
This type of situation relates to all items in the bariatric category. Another example would be a bariatric trapeze. This again would have to be billed using an E1399 and a full explanation of the weight capacity most manufacturers give for the standard trapeze bar. The weight of the patient and a statement that the patient would be at risk for injury if using a standard trapeze would also be necessary. Include the name, make and model of the heavy-duty trapeze and, of course, make sure you state that the criteria for a trapeze has been met.
Power & Manual Chairs
Hospital beds have heavy-duty codes, but power wheelchairs must be billed using the K0014 code for the base, along with the patient's height and weight on the CMN, and a full explanation of why the K0014 is needed over the K0011 or lower-level base. The criteria for a power chair must be addressed first. The name, make, model and MSRP of the base must also be given for pricing.
Manual heavy-duty chairs are K0006 (greater than 250 lbs.) and K0007 (greater than 300 lbs.). They are only capped rental, and if they do not specifically meet the weight capacity, they will downcode to a standard wheelchair (K0001).
If you have an exceptionally large patient who requires a bariatric manual base, you would use the K0009 code (other wheelchair base). Again, fully explain why a K0007 or lower-level chair would not meet the client's needs. You will need height and weight on the CMN and the name, make, model and MSRP of the base you are providing. Also include a specific statement as to why no other chair would meet the needs of the patient. Complete measurements are required.
Bariatric cushions and some position backs are being addressed in policy to some extent after July 1, 2004. Again, if you cannot find a specific item that meets the patient's needs, you will bill the NOC/Junk code for the specific category. Make sure all documentation is sent in with the claim.
The bariatric tilt-in-space should be coded with the standard tilt code. The DMERC/SADMERC has stated that they have decided not to pay for a bariatric tilt. This is being questioned through the RATC and regional DAC committees.
Remember, as long as documentation is appropriate and all information is sent with the claim, each item will be reviewed under individual consideration.
If you have any questions, contact me at U.S. Rehab: (803 )754-2090.
This article originally appeared in the October 2004 issue of Mobility Management.