Welcome to 2009…What Does This New Year Bring?

It’s another new year. This industry survived 2008, but as we know, 2009 is not looking any easier. Hopefully, you have already prepared and made the changes necessary. Other than the obvious reimbursement cuts, let’s look at what we are up against.


The new PDAC (Pricing, Data Analysis, and Coding Contractor) is what used to be known as the SADMERC. Technically, this transition occurred back in August, but we are still in the early stages. The contractor for the PDAC is Noridian Administrative Services (https://www.hmepdac.com). For the most part, this is a completely new staff, with the majority being located in Fargo, N.D.

This is obviously a big change for our industry; we have been working with the SADMERC since 1993. Dr. Doran Edwards, SADMERC medical director, had been in his position for more than 10 years. It took time, but he did learn much about the rehab industry. He certainly was one to listen and ask questions.
Now, we are back at square one. Dr. Bob Szczys is the medical director for the PDAC. I can say that during my two experiences in calling the help-line for both basic coding questions and coding application issues, the service has been very good. The staff has been helpful and has taken the time to do the proper research.

We still should expect the same speed bumps we have hit in the past. Hopefully, this time around we will just know how to better maneuver. As for any new codes, at this point we do not have any further information on the new manual wheelchair codes. So we must all wait and see.

2. Anticipating the Next Probes & Audits

Next is the question regarding Probes and Audits. What will be next? Are you a target?
Simply put, everyone is a target, and you need to be ready.

In the world of rehab, we are targeted due to the history of fraud and abuse of specific products within our industry. This is not a secret, so if you are providing Group 1 or 2 power mobility devices (PMDs), your files should always be ready to be reviewed.

That does not mean that others providing only Group 3 or 4 PMDs can look the other way. We all need to be certain that all required documentation is in our files and stamped within the required time limits. Don’t forget that power wheelchairs are not the only ones requiring home assessments. You must have home assessments for all manual wheelchairs, too — they just do not have to be completed in person. You can conduct those home assessments over the phone, but they must be done.

For those of you who also provide more basic mobility items (i.e., walkers) that can be rented or purchased up front, understand that Medicare expects you to give the patient the choice of renting or purchasing the item — you are not to make the choice for them. From past experience, I can tell you that Medicare has looked for such documentation in previous audits.

3. Understanding K0108

How about code K0108? I wish I had a magic wand that could make these claims processing issues go away. Unfortunately, I do not have such powers.
As a provider you need to be sure you stay on top of what is paid versus what is not. I still find many companies who leave money on the table because they did not realize that some of the K0108’s billed were not paid, while others were. This also holds true for code E1028 (Seating & Positioning Policy).

Be sure that your staff does not assume that all is good if they get a payment. They need to be sure it is the fully expected and correct payment. In the same breath, do not think that just because you get paid, the payment is right. If you find that you have been overpaid or paid inappropriately, go on and pull the proper forms and refund the monies. It is not worth the trouble it can cause down the road.

4. It’s Deductible Season.

Do not forget that you may be collecting extra payments from your clients to cover their annual deductible in the months of January and February. The annual 2009 deductible is $135. Be sure that you are verifying this information prior to delivery in order to ensure proper payment collection.

5. Changes for January 1, 2009

Now we come down to the key items that have gone into effect as of the first of the year.
First is the bad news, the 9.5-percent cut that is affecting most of the products our rehab community provides. Due to the “hold” on the competitive bidding initiative, all products that were involved in the program will be hit with a 9.5-percent cut across the board. Unfortunately, this does include all power products and their related options and accessories.

As we went to press, the fight to exclude complex rehab products was still going on. The industry had been successful in having complex rehab excluded from the bidding program; therefore, we are asking that these same products be excluded from the 9.5-percent cut.

For now, you need to be certain that you are able to successfully run your business with the cut. At this point, we do not know when we will win this battle, and if and when we do, we are not certain if Medicare will consider the change to be retroactive.

In order to separate options and accessories that go onto power vs. manual wheelchairs, a new modifier has been created. The KE modifier is required on all options and accessories that will be placed on a manual wheelchair.
If these same codes are billed with a manual wheelchair base, you will not use the new modifier; therefore, you will not see the reduction. This should not have to be said, but do not try to cheat the system by leaving the modifier off — you will get yourself into trouble.
Lastly, a small bit of good news: All HCPCS codes that were not a part of the competitive bidding program will see a 5-percent funding increase effective the first of the year. Again, be sure your system is updated.

We have a new president and a new administration, so many people are questioning how these changes will affect our industry. We are currently in a “wait and see” mode — and back to wishing for a crystal ball!

At this point, we do see good possibilities with the nomination (at press time) of Tom Daschle as the new head of the Department of Health & Human Services, of which the Centers for Medicare & Medicaid Services is an agency. Daschle has knowledge regarding our industry. But he also will be at the top of the pyramid. Everyone must stay involved and fight for what is needed. Stay updated, and be sure to work with your industry and state associations.

This article originally appeared in the January 2009 issue of Mobility Management.

About the Author

Claudia Amortegui is president of The Orion Group, a Colorado-based consulting company that specializes in DME reimbursement issues and assists suppliers with billing and Medicare questions.

Seating Benefits Podcast with Ride Designs