Post

The PMD Prior Authorization Demo program was established in 2012 in seven states and was expanded to an additional 12 states in October 2014. The program included the following codes:

• All power operated vehicles (K0800-K0802 and K0812)
• All standard power wheelchairs (K0813-K0829)
• All Group 2 complex rehabilitative power wheelchairs (K0835-K0843)
• All Group 3 complex rehabilitative power wheelchairs without power options (K0848-K0855)
• All pediatric power wheelchairs (K0890-K0891)
• Miscellaneous power wheelchairs (K0898)

This demo program was slated to end on Aug. 31, 2018; however, prior authorization for certain PMDs will continue and be expanded nationally beginning Sept. 1, 2018, as a condition of payment. While this is a positive outcome, there are some key points worth noting:

• Scooters are NOT included in this expansion and after Aug. 31, 2018, will no longer have prior authorization in those 19 states where it is currently available.
• The codes included in the prior authorization condition of payment (K0813- K0855) will require a prior authorization in ALL states beginning Sept. 1, 2018.
• K0856 and K0861 have been part of the condition of payment prior authorization since July 17, 2017, and will remain in effect.
• Beginning Sept. 1, 2018, ADMC will no longer be available for codes K0835-K0843 and K0848-K0855 as PA will be required.
• The ADMC program would review the base code and all accessories; however, the condition of payment prior authorization does NOT review all accessories, rather, ONLY those accessories on which the base is contingent (example: tilt for K0835, YES; swing away mounting hardware on K0835, NO).
• Lack of a prior authorization will result in a denial; whereas, for the PMD demo program in those 19 states, if a PA was not obtained, the claim would be developed and if approved, a 25% reduction to the allowable would apply.

Lack of a complete and thorough review of the medical records for wheelchair options and accessories, leaves the supplier vulnerable for potential overpayments in the event of a post payment audit. The van Halem Group is here to help you reduce the risk of costly denials and potential overpayments. What are benefits of our prescreen services prior to sending documents to prior authorization?

• Same/similar equipment review
  • Any same/similar equipment already in use that may be less than 5 years old.
  • Also, if there is same/similar equipment already in use, we review your medical records to ensure that they clearly document a significant change or decline in the beneficiary’s’ condition that would justify and support new equipment in less than 5 years.
• Face to face examination and the LCMP specialty evaluation review
  • Our clinicians determine if the recommended (or ordered) power wheelchair base, all related options and accessories, and/or all wheelchair seating are sufficiently justified and supported in the medical records.
  • This allows the supplier to include the required KX modifier with confidence that the medical records document sufficient justification should Medicare or another audit entity requests the medical records during a pre- or post-payment claim audit.
• ATP Evaluation review to ensure that the ATP’s participation in the selection of equipment is properly documented and satisfies Medicare ATP guidelines.
• Review of the home evaluation to ensure the document contains all the required information, such as room measurements, and the document has been signed and dated.

An additional benefit of vHG prescreen review, is the valuable staff education regarding the Medicare coverage and payment guidelines and recent updates to the LCDs, policy articles, and HCPC billing codes. Want to feel confident that the power wheelchairs and accessories you are providing meet coverage criteria? Sign up for our clinical prescreen services. Before you put out the equipment, let our clinical staff review your documentation to ensure the equipment meets coverage criteria. Our clinicians will review your documentation and provide you with an “approved” or “denied” status, along with recommendations for your referral source. Get your documentation right before you bill the claim to Medicare, and rest easy knowing you are protected should those claims be audited in the future.  In fact, we feel so confident in our clinical prescreen process, if you receive a denial on a claim that received vHG “approval”, we will appeal on your behalf – for free*! That is how confident we are in our prescreen program. Contact us for more information!