By Kim Turner, RN
As the Rehab Clinical Consultant at The van Halem Group, I work closely with our mobility clients on a daily basis. Recently, I have received an increase in inquiries related to the HCPCS eligible for Medicare ADMC and Prior Authorization.
Advance Determination of Medicare Coverage (ADMC) is a voluntary program that allows suppliers and beneficiaries to request prior approval of "eligible" items before delivery of the items to the beneficiary.
At this time, only customized wheelchairs (manual and power) are eligible for ADMC.
- Power Mobility Devices (PMDs) Eligible for ADMC include: K0890, K0891, K0013
- Manual Wheelchairs Eligible for ADMC include: E1161, E1231 - E1234, K0005, K0008, K0009
ADMC is a voluntary program. An affirmed ADMC decision means the beneficiary meets medical necessity requirements for Medicare. The affirmed ADMC is valid for six months from date of the decision.
COPPA- Power Mobility Devices (PMDs)
CMS has added an additional seven PMD codes to the required prior authorization process (K0857-K0860 and K0862-K0864). All new rental series claims for these PMDs nationwide with a date of delivery on or after July 22, 2019 must be associated with a prior authorization request as a condition of payment. Therefore, lack of a provisionally affirmed prior authorization request will result in a claim denial. MACs began accepting requests for the affected codes on July 08, 2019.
- HCPCS Required for COPPA as of July 22, 2019 for PMD: K0857 - K0860 and K0862 – K0864
- HCPCS Required for COPPA: K0813-K0829, K0835-K0843, K0848-K0856, and K0861
Any claim eligible for this program must be receive authorization before delivery of the item or it will be denied, as prior authorization is a condition of payment.
Important reminder: An affirmed prior authorization can be easily misunderstood, as the prior authorization review process does not include review of the specialty evaluation to determine the beneficiary’s medical necessity for ALL of the related wheelchair options and accessories and/or wheelchair seating. DME MACs will not review medical necessity for every accessory. The accessories listed below are often exempted from review during the prior authorization review:
- Headrests (E0955)
- Lateral hip/trunk/thigh supports (E0953, E0956)
- Swing away hardware (E1028)
- Electronics (E2310, E2311)
- Leg rests (K0195, K0108, E1010, E1012)
- Batteries (E2361, E2363, E2359)
- Wheelchair Seating, including skin protection, positioning, and combination seat cushions and positioning backs
An affirmed prior authorization does not prevent or absolve the supplier from audits. 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 overall big picture for Medicare is the post payment audit, which is where overpayments are determined.
To avoid becoming susceptible to Medicare overpayments, the van Halem Group can provide you prescreen services to help reduce risk of losing Medicare dollars for seating and accessories that are not reviewed during prior authorization. The van Halem Group is here to help you reduce the risk of what could amount to a substantial repayment to Medicare. Contact us today for more information!