[ DECEMBER 2009 ] 9 Advance Determination of Medicare Coverage Advance determination of Medicare coverage (ADMC) is a process by which the durable medical equipment Medicare administrative contractor (DME MAC) will provide the requestor with a coverage decision prior to delivery of an item. ELIGIBLE ITEMS The ADMC process is only available for the following wheelchair base Healthcare Common Procedure Code System (HCPCS) codes and related options and accessories: E1161 E1231 E1232 E1233 E1234 K0005 K0009 Manual adult size wheelchair, includes tilt in space Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, with seating system Wheelchair, pediatric size, tilt-in-space, folding, adjustable, with seating system Wheelchair, pediatric size, tilt-in-space, rigid, adjustable, without seating system Wheelchair, pediatric size, tilt-in-space, folding, adjustable, without seating system Ultralightweight manual wheelchair Not otherwise classified manual wheelchair base Power wheelchairs: Group 2 (K0835 K0843) Group 3 (K0856 K0864) Group 4 (K0877 K0886) Group 5 (K0890, K0891) Group 3 (K0848 K0855) provided with an alternative drive control interface (E2321 E2322, E2325, E2327 E2330) Group 4 (K0868 K0871) provided with an alternative drive control interface (E2321 E2322, E2325, E2327 E2330) Note: When a particular wheelchair base is eligible for ADMC, all wheelchair options and accessories ordered by the physician for that patient along with the base HCPCS code will be eligible for ADMC. SUBMITTING ADMC REQUESTS Effective February 18, 2008, all ADMC requests must be sent to National Government Services due to the medical review transition from the program safeguard contractors (PSC) (e.g., TriCenturion) to the DME MACs. Advance determination of Medicare coverage (ADMC) requests may either be mailed or sent by fax; ADMC requests cannot be submitted electronically. Note: There is a new address for mailed ADMC 132_1209 1
requests. When submitting an ADMC request by mail or fax, please include the ADMC cover sheet (located at the end of this chapter) with each request. The new mailing address for ADMC requests is: National Government Services, Inc. Attn: Medical Review ADMC P.O. Box 7018 Indianapolis, Indiana 46207-7018 Fax ADMC information to 317-595-4759 ADMC cover sheets are located on the National Government Services Web site: Go to www.ngsmedicare.com Select Durable Medical Equipment (DME) as your Business Type Select Jurisdiction B as your Region Select the Resources navigation category from the dark blue menu bar Select the Forms subnavigation option Select the Jurisdiction B DME MAC Advance Determination of Medicare Coverage Request Form PDF link ADMC REQUIREMENTS Certificates of Medical Necessity (CMNs) for manual and power wheelchair bases were discontinued effective April 1, 2006, prompting questions about what information should be submitted to support an ADMC request. Because CMNs are no longer required and will not be used for the submission of wheelchair claims, the first page of the ADMC request must contain all of the following demographic information: Beneficiary information Name Health Insurance Claim number (HICN) Address Date of birth Place of service ICD-9-CM diagnosis code (narrative description is not sufficient) Supplier information Name Provider Transaction Access Number (PTAN) or National Provider Identifier (NPI) Address Phone number Physician s information Name PTAN or NPI Address Phone number 132_1209 2
Note: If the information listed above is not present, ADMC requests received by the DME MACs will be rejected. Manual Wheelchairs For manual wheelchairs, the supplier must include the following (1 3): 1) A detailed written order that lists the specific wheelchair base that is to be provided and each option/accessory that will be separately billed. The order must also specify which HCPCS code is associated with each item on the order. This information may be entered by the supplier but the order must be signed and dated by the physician. 2) Information from the patient s medical record that documents that the coverage criteria defined in the medical policy on manual wheelchairs have been met. 3) A home assessment which establishes that the beneficiary or caregiver is able to use the wheelchair ordered to assist with activities of daily living (ADLs) in the home. For more information on coverage criteria, coding guidelines, and documentation requirements, refer to the local coverage determinations for manual wheelchairs, wheelchair options and accessories, and wheelchair seating on the National Government Services Web site: Go to www.ngsmedicare.com Select Durable Medical Equipment (DME) as your Business Type Select Jurisdiction B as your Region Select the Coverage navigation category from the dark blue menu bar Select the Local Medical Policy subnavigation option Locate the desired wheelchair LCD in the Active Policies index table and select either the link to the LCD (left column) or the Policy Article (right column) Power Wheelchairs For power wheelchairs, the supplier must include all of the following items (1 5): 1) The order that the supplier received within 45 days following the completion of the face-to-face examination. This order must contain the following elements: Beneficiary name Description of the item; this may be general, (e.g., power wheelchair or power mobility device ) or may be more specific Date of the face-to-face examination. If the evaluation involved multiple visits, enter the date of the last visit. (Refer to the Power Wheelchairs LCD for additional information.) Pertinent diagnoses/conditions that relate to the need for the power wheelchair Length of need Physician s signature Date of physician signature There must be a date stamp or equivalent on the order to indicate when it was received by the supplier. 132_1209 3
2) A statement that the wheelchair is provided by a supplier that employs a Rehabilitation Engineering and Assistive Technology Society of North America (RESNA)-certified assistive technology professional (ATP) who specializes in wheelchairs and who has direct, in-person involvement in the wheelchair selection for the patient 3) A detailed product description (which includes information previously contained in the detailed written order) that lists the specific wheelchair base that is to be provided and each option/accessory that will be separately billed. This document must also specify which HCPCS code is associated with each item on the list. This information may be entered by the supplier but the document must be signed and dated by the physician. (The signature date on this document does not have to be within 45 days following the face-to-face exam.) For ADMC requests that are received on or after August 24, 2006, the document must also include the supplier s charge and the Medicare fee schedule allowance for each item. If there is no fee schedule allowance, enter Not Applicable. 4) A copy of the report of the face-to-face examination by the physician and other licensed/certified medical professionals (LCMPs), if applicable. There must be a date stamp or equivalent on the report(s) to indicate when they were received by the supplier. For ADMC requests received on or after August 10, 2006, LCMPs reports that are to be considered part of the face-to-face examination must include an attestation statement from the supplier indicating that the LCMP has no financial relationship with the supplier. Refer to the Power Wheelchairs policy for guidance on the type of documentation to be included. Note: If the power wheelchair is a replacement within five years of one billed with the same HCPCS code that was previously covered by Medicare, a face-to-face examination is not required. 5) A home assessment which establishes that the beneficiary is able to use the wheelchair ordered to assist with ADLs in the home. For more information on coverage criteria, coding guidelines, and documentation requirements, refer to the LCDs for motorized/power wheelchairs, wheelchair options and accessories, and wheelchair seating on the National Government Services Web site: Go to www.ngsmedicare.com Select Durable Medical Equipment (DME) as your Business Type Select Jurisdiction B as your Region Select the Coverage navigation category from the dark blue menu bar Select the Local Medical Policy subnavigation option Locate the desired wheelchair LCD in the Active Policies index table and select either the link to the LCD (left column) or the Policy Article (right column) Additional Guidance Any information provided that explains the medical necessity for separately billed options and accessories must use the same short description for the item that is used in the detailed product description or detailed written order. 132_1209 4
If the patient s weight and/or height are needed to support the medical necessity for items that are ordered, that information should be included on the first page of the ADMC request. Even if the majority of the face-to-examination is performed by an LCMP, the ADMC request must also include the report of the face-to-face examination with the physician. Include the manufacturer, the product name, the model number, and the width of wheelchair cushion(s) that are provided. Make certain that the product is listed on the Pricing, Data Analysis, and Coding Contractor (PDAC) Product Classification List and that the HCPCS code on the ADMC is the one specified by the PDAC. Suppliers are reminded that if an affirmative determination is made on the wheelchair base but individual options/accessories are denied, there may be no resubmission or other request for an ADMC determination on these. If these items are provided and denied at the time of claim submission, the supplier may present additional information to justify coverage through the appeals process. ADMC DETERMINATION Upon receipt of an ADMC request, the DME MAC Medical Review Department will make a determination within 30-calendar days. The DME MAC Medical Review Department will provide the supplier and beneficiary with its determination, either affirmative or negative, in writing. If it is a negative determination, the letter will indicate why the request was denied, e.g., not medically necessary, insufficient information submitted to determine coverage, and/or statutorily noncovered. If a wheelchair base receives a negative determination, all accessories will also receive a negative determination. If a wheelchair base receives an affirmative determination, each accessory will receive an individual determination. Affirmative Determination An affirmative determination only relates to whether the item is medically necessary based on the information submitted. An affirmative determination does not provide assurance that the beneficiary meets Medicare eligibility requirements nor does it provide assurance that any other Medicare requirements (e.g., place of service, Medicare Secondary Payer) have been met. Only upon submission of a complete claim can the DME MAC make a full and complete determination. An affirmative determination does not extend to the price that Medicare will pay for the item. Finally, the DME MAC may review selected claims on a prepayment or postpayment basis and may deny a claim or request an overpayment if it determined that an affirmative determination was made based on incorrect information. An affirmative ADMC is only valid for items delivered within six months following the date of the determination. If the wheelchair is not delivered within that time, the supplier has the option of either submitting a new ADMC request (prior to providing the item) or filing a claim (after providing the item). If the item is provided within six months following an affirmative determination, and if the claim is for all the same items that were listed on the ADMC request, the documentation that supports the medical 132_1209 5
necessity of the item does not need to be submitted with the claim. If any of the items on the ADMC request were described by HCPCS code K0108 and if those items were provided, the supplier must ensure that the narrative description used on the claim matches the narrative description used on the ADMC determination letter. If a wheelchair base receives an affirmative determination, the supplier may not submit a separate ADMC request for additional accessories. If options or accessories are provided that were not listed on the ADMC request, the supplier should submit whatever information is appropriate to document the medical necessity for the new item(s). Negative Determination A negative ADMC determination may not be appealed because it does not meet the regulatory definition of an initial determination since no request for payment is being made. However, if the ADMC request for the wheelchair base is denied and the supplier obtains additional medical documentation, a new ADMC request may be resubmitted with all pertinent medical documentation and forms. ADMC requests may only be resubmitted once during the six-month period following a negative determination. If the wheelchair base is approved, but one or more accessories are denied, an ADMC request may not be resubmitted for those accessories. If a supplier provides a wheelchair and/or accessories following a negative determination, a claim for the item should be submitted. If new information is provided with the claim, coverage will be considered. If the claim is denied, it may be appealed through the usual process. 132_1209 6
Medicare Jurisdiction B DME MAC Advance Determination of Medicare Coverage Request Form Note: Please submit this completed Advance Determination of Medicare Coverage (ADMC) Request Form along with supporting medical necessity documentation. Company Name: Company Address: NPI or PTAN: Contact Name: Telephone Number: Note: If you would like the ADMC returned to you by fax rather than by mail, please provide your fax number: Beneficiary Name: Beneficiary Address: Health Insurance Claim Number (HICN): Date of Birth: Place of Service: ICD 9: Physician s Name: Physician s Address: Telephone Number: National Provider Identifier: Number of Pages (including coversheet): Mail Completed Form To: Fax Completed Form To: National Government Services, Inc. 317 595 4759 Attn: Medical Review ADMC P.O. Box 7018 Indianapolis, Indiana 46207 7018 National Government Services, Inc. Page: 1 of 1 261_1109