Power wheel chair and prosthesis discussion responses

Power wheel chair and prosthesis discussion responses

Sean Saunders

7/29/2013

Sorry for the delay but here are the responses I got for the following
question. Thanks to everyone who replied!

Hello all,

I know we have had some recent discussions about providing a patient that
has a power wheelchair with prostheses but it seems to have some
conflicting information from other sources.

In the September 2011 O and P Almanac it states that the Medicare policy
has been changed and now allows for both to be provided. The responses
that were sent out on July 3 from a similar question here on the board
overwhelmingly indicated that it would not be a covered service.

We have a bilateral BKA that has ill fitting prostheses that we would like
to get replaced but are not sure how to proceed as he recently got a power
chair. He did walk into our facility with just a cane and is independent
with transfers so we can easily make a claim that he is at least a K2
ambulator.

Has anyone dealt with Medicare recently with a patient that has a power
chair and get coverage or are most just declining due to lack of
reimbursement in the past?

I did contact Medicare and of course they state they can not guarantee
payment but there is nothing specifically in place that would deny a
patient both devices but if it was audited (and we know how that's been
going) it is possible for it to be denied because the primary reason for a
power chair is that they are non-ambulatory.

Sorry for rehashing this subject and thanks for any help you can provide.





**
We have only had one instance where because of a power wheelchair, Medicare
denied a KO. We haven't had any issues with prosthetics as of yet;
however, for the KO case, we had no idea the patient had a power
wheelchair. Always ambulates in our office with a walker, drives his own
car to appts., etc. We are at the ALJ level of appeals at this point. So,
we now ask our patient if they have a power wheelchair. Medicare stated
that because the patient had a power wheelchair, the patient was not
ambulatory, therefore the Knee Orthosis was not medically necessary per the
LCD. I have argued that he is indeed ambulatory based on our documentation
and physical evidence that he drives himself to our appointments, walks
himself into our office and around our office, etc. So far, no success in
getting the denial overturned.

No personal experience here, but I think you'd want to cover you bases by
having a physician state that they objectively verified that pt is K2
(watched how far they ambulate, performed AMPpro test, etc) and that the
power chair is inappropriate. A patient only qualifies for a power chair
if they are non-ambulatory, so you will need a physician to document,
possibly with video, that the patient is a functional ambulator.

Look at the Medicare policy for power chairs too. I believe people have to
be able to independently transfer to and from the chair. If he can't
transfer without a prosthesis then he needs the prosthesis. I'm not sure
transfers to power chair make him K2 unless he can also tackle stairs and
curbs.


I have 2 cases to tell you. The first is a unilateral BKA that has a
PWC and needs a socket replacement. I have spoken with our Medicare
rep, Zita Upchurch, and she told me that if Medicare paid for the
chair, they are declared non-ambulatory, regardless if they can
walk. To get the chair, that provider had to prove that the pt cannot
ambulate. We have been told that even if we can document that our pt
is a K2 or K3, Medicare will deny it because it conflicts with the
qualifications for the chair that they have on file and reference for
all other claims in DMEPOS. I was told that there is a chance that it
may be covered if the pt is listed by us and the MD as a K1, for
transfer purposes into the chair. It may still get audited, but it
will be easier to win if all notes states that the socket replacements
are needed for K1 activities to help the pt get into the chairs. It
sounds like lying or downgrading the pt, but as Medicare sees it, the
pt cannot be anything higher than a K1 to qualify for the chair, which
has already been paid for. For this pt, we were told to get an ABN. We
were told that it will get flagged for an audit and maybe denied
because of the chair. The pt is currently getting all documentation
from her MDs and therapists to help in the event of an audit, and
saving her money for her prosthetic items in case she has to pay.

Our 2nd pt. We have a bilateral BKA with a powerchair that was fit a few
months ago (March) before we knew about the conflict. She was fit with K1
prostheses using SACH feet. The MD's notes listed her as K1, as did ours.
We got paid by Medicare with no problems so far.


I've heard many people state Medicare will not pay for power chairs/scooters

and prosthetics at the same time. This is not correct..at least in region C.

We routinely provide prosthetics to persons with power chairs and have never

had a problem. It doesn't matter if they get the prosthesis first or the

power chair first. Medicare has never denied one due to the other.
Hello...I refer all my questions that I cannot seem to get a straight
answer for..to these folk's. I, attended a Webinar last week and we were
told during the meeting, that if we had any questions what so ever to
contact them. They do not leave a phone number (of course).

<Email Address Redacted> This is a department within Medicare that seems
to have alllllllllll the answers (on a daily basis) seeing that we seem to
have daily Medicare Supplier Rules changes. It's like I come in everyday
now wondering what changed over nite. I can hardly keep up with the
revolving door of constant changes.

Good Luck!