The Medicare K0005 Mystery Explained Presented by: Andria Pritchett

Transcription

1 The Medicare K0005 Mystery Explained Presented by: Andria Pritchett

2 DISCLAIMER This information is the property of Numotion. It may be freely distributed in its entirety, but may not be modified, sold for profit or used in commercial documents. The information is provided as is without any expressed or implied warranty. While all information in this document is believed to be correct at the time of writing, this document is for educational purposes only and does not purport to provide legal advice. All models, methodologies and guidelines are undergoing continuous improvement and modification by Numotion. The most current edition of the information contained in this release can be found on the Numotion website at The identification of an organization or product in this information does not imply any form of endorsement. CPT codes, descriptors, and other data only are copyright 2015 American Medical Association (or such other date of publication of CPT). All Rights Reserved. 2

3 LEARNING OBJECTIVES Understand the K0005 ultra lightweight manual wheelchair Equipment criteria? Specs? Demonstrate a complete understanding of Medicare s coverage criteria for a K0005 ultra lightweight manual wheelchair Upon completion of this course, the participant will be able to describe clinical and special considerations to be taken into account when reviewing a K0005 ultra lightweight manual wheelchair. 3

4 PAINTING THE PICTURE, SOLVING THE PUZZLE, BRIDGING THE GAP 4

5 K0005-ULTRA LIGHTWEIGHT MANUAL WHEELCHAIR Equipment Criteria Weight: < 30 lbs w/o front riggings Seat Width: 14, 16 or 18" * Seat Depth: 14 or 16" * Seat Height: > 17" and < 21" ** Back Height: Not defined Arm Style: Fixed or detachable Footrests: Fixed or S/A detachable Footrest Ext: 16-21" Warranty: Lifetime on frame and crossbrace Axle Plate: Fully adjustable 5

6 MANUAL WHEELCHAIR GENERAL COVERAGE CRITERIA Per the Manual Wheelchair LCD (L11454), a manual wheelchair is covered if: Criteria A, B, C, D and E are met; and Criterion F or G is met A. The beneficiary has a mobility limitation that significantly impairs his/her ability to participate in one or more mobility-related activities of daily living (MRADLs) such as toileting, feeding, dressing, grooming, and bathing in customary locations in the home. A mobility limitation is one that: 1. Prevents the beneficiary from accomplishing an MRADL entirely, or 2. Places the beneficiary at reasonably determined heightened risk of morbidity or mortality secondary to the attempts to perform an MRADL; or 3. Prevents the beneficiary from completing an MRADL within a reasonable time frame. 6

7 MANUAL WHEELCHAIR GENERAL COVERAGE CRITERIA Per the Manual Wheelchair LCD (L11454), a manual wheelchair is covered if: Criteria A, B, C, D and E are met; and Criterion F or G is met B. The beneficiary s mobility limitation cannot be sufficiently resolved by the use of an appropriately fitted cane or walker. AND C. The beneficiary s home provides adequate access between rooms, maneuvering space, and surfaces for use of the manual wheelchair that is provided. AND D. Use of a manual wheelchair will significantly improve the beneficiary s ability to participate in MRADLs and the beneficiary will use it on a regular basis in the home. AND E. The beneficiary has not expressed an unwillingness to use the manual wheelchair that is provided in the home. AND 7

8 MANUAL WHEELCHAIR GENERAL COVERAGE CRITERIA Per the Manual Wheelchair LCD (L11454), a manual wheelchair is covered if: Criteria A, B, C, D and E are met; and Criterion F or G is met F. The beneficiary has sufficient upper extremity function and other physical and mental capabilities needed to safely self-propel the manual wheelchair that is provided in the home during a typical day. Limitations of strength, endurance, range of motion, or coordination, presence of pain, or deformity or absence of one or both upper extremities are relevant to the assessment of upper extremity function. OR G. The beneficiary has a caregiver who is available, willing, and able to provide assistance with the wheelchair. AND 8

9 THE K0005 FUNDING MYSTERY MEDICARE COVERAGE CRITERIA Per the Manual Wheelchair LCD (L11454) a K0005 is covered if (1) or (2) is met and (3) and (4) are met: 1. The beneficiary must be a full-time manual wheelchair user. OR 2. The beneficiary must require individualized fitting and adjustments for one or more features such as, but not limited to, axle configuration, wheel camber, or seat and back angles, and which cannot be accommodated by a K0001 through K0004 manual wheelchair. AND 9

10 THE K0005 FUNDING MYSTERY MEDICARE COVERAGE CRITERIA Per the Manual Wheelchair LCD (L11454) a K0005 is covered if (1) or (2) is met and (3) and (4) are met: 3. The beneficiary must have a specialty evaluation that was performed by a licensed/certified medical professional (LCMP), such as a PT or OT, or physician who has specific training and experience in rehabilitation wheelchair evaluations and that documents the medical necessity for the wheelchair and its special features. The LCMP may have no financial relationship with the supplier. AND 10

11 THE K0005 FUNDING MYSTERY MEDICARE COVERAGE CRITERIA Per the Manual Wheelchair LCD (L11454) a K0005 is covered if (1) or (2) is met and (3) and (4) are met: 4. The wheelchair is provided by a Rehabilitative Technology Supplier (RTS) that employs a RESNAcertified Assistive Technology Professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient. AND 11

12 THE K0005 FUNDING MYSTERY MEDICARE COVERAGE CRITERIA Per the Manual Wheelchair LCD (L11454) a K0005 is covered if (1) or (2) is met and (3) and (4) are met: If documentation of the medical necessity for a K0005 wheelchair is requested, it must include: a description of the beneficiary s routine activities the types of activities the beneficiary frequently encounters whether the beneficiary is fully independent in the use of the wheelchair Describe the features of the K0005 base which are needed compared to the K0004 base 12

13 K0005 CLINICAL CONSIDERATIONS Customer is unable to functionally/efficiently propel a standard, lightweight or high strength lightweight wheelchair due to upper or lower extremity weakness, endurance issues, cardiopulmonary problems, pain, fatigue, arthritis, spasticity, decreased range of motion and/or orthopedic deformities. Customer can and does propel in an ultra lightweight manual wheelchair. Customer needs the ultra lightweight manual wheelchair to perform MRADLs that cannot be performed in a standard, lightweight or high strength lightweight manual wheelchair (doctor s appointment, school, job, church). Customer s body dimensions cannot be accommodated in the manual wheelchair seat dimensions of a standard, lightweight or high strength lightweight wheelchair, but the customer s weight can. * 13

14 K0005- CONTINUED Customer requires a specific back height other than standard due to poor balance, postural control, abnormal tone and/or orthopedic issues. Customer has upper extremity weakness, decreased range of motion, spasticity, and/or poor endurance that requires maximum adjustment of rear wheel position for completion of their MRADLs. Customer has poor balance, postural control, abnormal tone and/or orthopedic issues that require the ability to change seat angle and/or orientation in space through a fully adjustable axle plate. * Products in this code frequently have multiple seat widths and depths in 1 increments. ** Products in this code frequently have lower STFH available 14

15 K0005 SPECIAL CONSIDERATIONS - RECAP The beneficiary must be a full time manual wheelchair user; or require individualized fitting and adjustments for one or more features such as, axle configuration, wheel camber, seat slope, etc. It must be documented that these adjustments/fittings cannot be accommodated by a K0001-K0004 base. K0005 Ultra lightweight manual wheelchairs are highly configurable manual wheelchairs for highly active, full-time users. Documentation must reflect activity patterns that frequently require the end-user to go out into the community for the purpose of independently accomplishing high-level MRADL activities. Examples of these might include a combination of; shopping, work, school, banking, independently loading and unloading from a vehicle etc. 15

16 Questions?

17 Thank You!