Payment policy for power operated wheel chair and Oxygen Equipment

Payment for Power-Operated Vehicles that May Be Appropriately Used as Wheelchair



The allowed payment amount for a power-operated vehicle that may be appropriately used as wheelchair, including all medically necessary accessories, is the lowest of the:

• Actual charge for the power-operated vehicle, or

• Fee schedule amount for the power-operated vehicle.

Oxygen and Oxygen Equipment


For oxygen and oxygen equipment, contractors pay a monthly fee schedule amount per beneficiary. Unless otherwise noted below, the fee covers equipment, contents and supplies. Payment is not made for purchases of this type of equipment.

When an inpatient is not entitled to Part A, payment may not be made under Part B for DME or oxygen provided in a hospital or SNF. (See the Medicare Benefit Policy Manual, Chapter 15) Also, for outpatients using equipment or receiving oxygen in the hospital or SNF and not taking the equipment or oxygen system home, the fee schedule does not apply.

There are a number of billing considerations for oxygen claims. The chart in §130.6 indicates what amounts are payable under which situations.

Effective for claims on or after February 14, 2011, payment for the home use of oxygen and oxygen equipment when related to the treatment of cluster headaches is covered under a National Coverage Determination (NCD).

Exhibit 2 - How Medicare Pays For Electric Wheelchairs

If you need an electric wheelchair prescribed by your doctor, you may already know that Medicare can help pay for it. Medicare requires (specify name of supplier) to give you the option of either renting or purchasing it. If you decide that purchase is more economical, for example, because you will need the electric wheelchair for a long time, Medicare pays 80 percent of the allowed purchase price in a lump sum amount. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. However, you must elect to purchase the electric wheelchair at the time your medical equipment supplier furnishes you the item. If you elect to rent the electric wheelchair, you are again given the option of purchasing it during your 10th rental month.

If you continue to rent the electric wheelchair for 10 months, Medicare requires (specify name of supplier) to give you the option of converting your rental agreement to a purchase agreement. This means that if you accept this option, you would own the medical equipment. If you accept the purchase option, Medicare continues making rental payments for your equipment for 3 additional rental months. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After these additional rental payments are made, title to the equipment is transferred to you. You have until (specify the date one month from the date the supplier notifies the patient of this option) to elect the purchase option. If you decide not to elect the purchase option, Medicare continues making rental payments for an additional 5 rental months, a total of 15 months. After a total of 15 rental months have been paid, title to the equipment remains with the medical equipment supplier; however, the supplier may not charge you any additional rental amounts.

In making your decision to rent or purchase the equipment, you should know that for purchased equipment, you are responsible for 20 percent of the service charge each time your equipment is actually serviced and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. However, for equipment that is rented for 15 months, your responsibility for such service is limited to 20 percent coinsurance on a maintenance and servicing fee payable twice per year whether or not the equipment is actually serviced.

Additional Purchase Option for Electric Wheelchairs -

Effective May 1, 1991, suppliers must give beneficiaries entitled to electric wheelchairs the option of purchasing them at the time the supplier first furnishes the item. Contractors make no rental payment for the first month for electric wheelchairs until the supplier notifies the contractor that it has given the beneficiary the option of either purchasing or renting. Information contained in Exhibit 2 may be furnished to beneficiaries by suppliers to help them make a rent/purchase decision. Contractors provide copies of Exhibit 2 to suppliers. Payment must be on a lump-sum fee schedule purchase basis where the beneficiary chooses the purchase option. If the beneficiary declines to purchase the electric wheelchair initially, contractors make rental payments in the same manner as any other capped rental item, including the instructions in §30.5.2.


Exhibits

Exhibit 1 - The Rent/Purchase Option

You have been renting your (specify the item(s) of equipment) for 10 continuous rental months. Medicare requires (specify name of supplier) to give you the option of converting your rental agreement to a purchase agreement. This means that if you accept this option, you would own the medical equipment. If you accept the purchase option, Medicare continues making rental payments for your equipment for 3 additional rental months. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After making these additional rental payments, title to the equipment is transferred to you. You have until (specify the date one month from the date the supplier notifies the patient of this option) to elect the purchase option. If you decide not to elect the purchase option, Medicare continues making rental payments for an additional 5 rental months, a total of 15 months. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. After a total of 15 rental months have been paid, title to the equipment remains with the medical equipment supplier; however, the supplier may not charge you any additional rental amounts.


In making your decision to rent or purchase the equipment, you should know that for purchased equipment your supplier may charge you each time your equipment is actually serviced. You are responsible for the 20 percent coinsurance amounts and, for unassigned claims, the balance between the Medicare allowed amount and the supplier's charge. However, for equipment that is rented for 15 months, your responsibility for such service is limited to 20 percent coinsurance on a maintenance and servicing fee payable twice per year whether or not the equipment is actually serviced.

Wheelchairs (customized)

Please follow the billing guidelines below when you bill Blue Cross for customized wheelchairs:

File the entire customized wheelchair claim using HCPCS code E1220, and we will reimburse the entire claim at Manufacturer's Suggested Retail Price (MSRP) minus 25 percent discount of charges. These claims require detailed invoices to be submitted. To expedite this process, please submit hardcopy paper claims and supporting documents.

• Evaluation and set-up fees will not be reimbursed separately.

• Use K0739 to bill for equipment maintenance that is not covered under the warranty.

Reimbursement will be based on the allowable charge.



Wheelchairs (non-customized)

Wheelchair accessories must be billed on the same claim form as the wheelchair itself. Multiple accessories using code K0108 should each be billed on a separate line.

For purchased DME/HME, the participating DME/HME supplier must provide a one-year warranty agreement to the member. This warranty agreement may include some nominal monetary fee that is billable to the member. The participating DME/HME supplier must always inform the member about any DME/HME warranty provided by the manufacturer.

The DME/HME supplier agrees to provide all DME/HME services and supplies and orthotic and prosthetic devices, if applicable, according to the following standards:

• Free delivery;

• Free installation;

• Seven day-a-week, 24-hour emergency services by both technicians and professionals;

• Rental equipment repair and maintenance service (same day service, if required);

• Clinical professionals for patient education and home management, and, where necessary, written graphically-illustrated patient education and instruction manuals; and

• Availability of standard/economical models that meet the patient’s needs and quality standards.