power wheelchair and prosthetics
Linda Mason Cp
Description
Collection
Title:
power wheelchair and prosthetics
Creator:
Linda Mason Cp
Date:
11/13/2006
Text:
Dear Colleagues, Here are the responses. I am going out on a limb:) as there are no clear rulings.
Thank you for all the responses.
Linda Mason, CP
I hadn't heard of that rule before (I am also young in my experience) but I have had a couple transfemoral pt's that are mainly K1, borderline K2, that have a motorized chair, especially for a situation that would normally require them to walk long distances
According to AOPA, the rules changed last year for the wheelchair suppliers. What the problem was is that the Dr. had to write the Rx. to say that the pt. was K-0 in order to receive the chair. The rules have changed the language and don't need to have a K rating for the chair. I have supplied a couple of my patients with prostheses and supplies that have chairs and have not been denied, at least from Medicare.shopping, casinos,
etc
Please post replies. I have run into the same dilemma. I have heard they won't pay, but yet I have built legs for folks with a chair and gotten paid any way (found out after the fact about the chair)
I also have a medical supply store, and there is no problem with providing a
prosthesis and a wheelchair at the same time. I know many people on this
list server have stated otherwise, but in 25 years of business it has never
been an issue for us. And as you stated, Medicare also sees no problem in
doing this.
The representative is correct, the Medicare manual does not say both cannot be provided. The problem comes in when the wheelchair provider must have an M.D. certify the patient cannot ambulate. (Read the section on qualifications for power chairs). This automatically places the patient in a K-0 category. Now when the prosthetist tries to certify a higher ambulatory level of ambulation the prosthesis is denied because the patient already has a means of mobilization (ie: the power chair). The end result is the prosthesis is denied as not medically necessary. One caveat, if the patient rents the chair, medicare will still cover the prosthesis because the chair is viewed as temporary. Medicare will pay much more over the life of the chair for the rental, but whoever said Medicare was efficient?
I always try to inform new amputees on this loop hole as soon as I can. Most amputees are trying to do Medicare and the government a favor and save them money by purchasing, then the government bites them in the butt for it.
To my knowledge, I do not believe there ever was any official policy out there that said that they cannot have both.
BUT, to qualify for a power chair (which I used to work for an O&P company that was also BIG into powerchairs, and all DME (yuck!!!)), the patient had to have a CMN stating that they cannot ambulate at all basically. That is the only way they can qualify for a powerchair. They cannot walk more than so much, or they have problems with their arms that they cannot push a manual wheelchair, etc.
They may have changed those rules, I don't know, and I don't think anyone at Medicare can answer that question either. I have never been able to find anyone there that really knows what is going on. They always just refer you back to the manual, or to go online and look at the manual there. It is like reading foreign legal Good luck, let me know if anyone can give an answer that is accurate and for sure.
My company supplies both chair and prosthesis. No restrictions on the prosthesis although I would say K 1 or at best K 2. Supplying the chair would be a bigger problem. I suspect Medicare would reject this the first time around. If you are involved in the chair you will find it is infinitely more difficult to get the chair than the pros. Medicare requires patient to have a face to face with the physician to be evaluated for the chair. Progress notes must address 11 items Medicare has set up.
PLEASE MAKE SURE THAT YOU READ THE LCD POLICIES FOR PROSTHESIS. THE PATIENT
MUST BE AMBULATORY AND MOTIVATED TO AMBULATE. THE FUNCTION LEVEL MUST BE
IDENTIFIED AS WELL IN YOUR DOCUMENTATION AND ON THE PRESCRIPTION. IF THE
PATIENT IS USING A POWERED WHEEL CHAIR, WHAT MOTIVATES THE PATIENT TO
AMBULATE? MAKE SENSE? If the patient receives both, don't be surprised if
Medicare denies your claim for a prosthesis as not medically necessary.
Just words of caution.
Please post replies. I have run into the same dilemma. I have heard they won't pay, but yet I have built legs for folks with a chair and gotten paid any way (found out after the fact about the chair)
FYI, we have received rejections a patient has received one or the other prior.
Be sure to have an ABN signed.
________________________________________________________________________
Check out the new AOL. Most comprehensive set of free safety and security tools, free access to millions of high-quality videos from across the web, free AOL Mail and more.
Thank you for all the responses.
Linda Mason, CP
I hadn't heard of that rule before (I am also young in my experience) but I have had a couple transfemoral pt's that are mainly K1, borderline K2, that have a motorized chair, especially for a situation that would normally require them to walk long distances
According to AOPA, the rules changed last year for the wheelchair suppliers. What the problem was is that the Dr. had to write the Rx. to say that the pt. was K-0 in order to receive the chair. The rules have changed the language and don't need to have a K rating for the chair. I have supplied a couple of my patients with prostheses and supplies that have chairs and have not been denied, at least from Medicare.shopping, casinos,
etc
Please post replies. I have run into the same dilemma. I have heard they won't pay, but yet I have built legs for folks with a chair and gotten paid any way (found out after the fact about the chair)
I also have a medical supply store, and there is no problem with providing a
prosthesis and a wheelchair at the same time. I know many people on this
list server have stated otherwise, but in 25 years of business it has never
been an issue for us. And as you stated, Medicare also sees no problem in
doing this.
The representative is correct, the Medicare manual does not say both cannot be provided. The problem comes in when the wheelchair provider must have an M.D. certify the patient cannot ambulate. (Read the section on qualifications for power chairs). This automatically places the patient in a K-0 category. Now when the prosthetist tries to certify a higher ambulatory level of ambulation the prosthesis is denied because the patient already has a means of mobilization (ie: the power chair). The end result is the prosthesis is denied as not medically necessary. One caveat, if the patient rents the chair, medicare will still cover the prosthesis because the chair is viewed as temporary. Medicare will pay much more over the life of the chair for the rental, but whoever said Medicare was efficient?
I always try to inform new amputees on this loop hole as soon as I can. Most amputees are trying to do Medicare and the government a favor and save them money by purchasing, then the government bites them in the butt for it.
To my knowledge, I do not believe there ever was any official policy out there that said that they cannot have both.
BUT, to qualify for a power chair (which I used to work for an O&P company that was also BIG into powerchairs, and all DME (yuck!!!)), the patient had to have a CMN stating that they cannot ambulate at all basically. That is the only way they can qualify for a powerchair. They cannot walk more than so much, or they have problems with their arms that they cannot push a manual wheelchair, etc.
They may have changed those rules, I don't know, and I don't think anyone at Medicare can answer that question either. I have never been able to find anyone there that really knows what is going on. They always just refer you back to the manual, or to go online and look at the manual there. It is like reading foreign legal Good luck, let me know if anyone can give an answer that is accurate and for sure.
My company supplies both chair and prosthesis. No restrictions on the prosthesis although I would say K 1 or at best K 2. Supplying the chair would be a bigger problem. I suspect Medicare would reject this the first time around. If you are involved in the chair you will find it is infinitely more difficult to get the chair than the pros. Medicare requires patient to have a face to face with the physician to be evaluated for the chair. Progress notes must address 11 items Medicare has set up.
PLEASE MAKE SURE THAT YOU READ THE LCD POLICIES FOR PROSTHESIS. THE PATIENT
MUST BE AMBULATORY AND MOTIVATED TO AMBULATE. THE FUNCTION LEVEL MUST BE
IDENTIFIED AS WELL IN YOUR DOCUMENTATION AND ON THE PRESCRIPTION. IF THE
PATIENT IS USING A POWERED WHEEL CHAIR, WHAT MOTIVATES THE PATIENT TO
AMBULATE? MAKE SENSE? If the patient receives both, don't be surprised if
Medicare denies your claim for a prosthesis as not medically necessary.
Just words of caution.
Please post replies. I have run into the same dilemma. I have heard they won't pay, but yet I have built legs for folks with a chair and gotten paid any way (found out after the fact about the chair)
FYI, we have received rejections a patient has received one or the other prior.
Be sure to have an ABN signed.
________________________________________________________________________
Check out the new AOL. Most comprehensive set of free safety and security tools, free access to millions of high-quality videos from across the web, free AOL Mail and more.
Citation
Linda Mason Cp, “power wheelchair and prosthetics,” Digital Resource Foundation for Orthotics and Prosthetics, accessed November 24, 2024, https://library.drfop.org/items/show/227617.
