MEDICARE POWERED MOBILITY AND DME REPAIR AND REPLACEMENT POLICY

MEDICARE POWERED MOBILITY REPAIR AND REPLACEMENT POLICY
Medicare payment may be made for repair and replacement of medically required DME. This includes equipment that had
been in use before the user enrolled in Part B of the Medicare program and the user qualifies for the equipment under the
Medicare coverage criteria.
Payment for repairs and maintenance may not include payment for parts and labor covered under a manufacturer or
supplier’s warranty.
Repairs
To repair means to fix or mend and to put the equipment back into good condition after damage or wear.
Repairs to equipment, which a beneficiary owns, are covered when necessary to make the equipment serviceable.
However, payment will not be made for repairs to previously denied equipment.
If the expense for repairs exceeds the estimated expense of purchasing or renting another piece of equipment for the
remaining period of medical need, no payment can be made for the excess amount.
A new physician’s order is not needed for repairs.
More extensive maintenance which, based on the manufacturers’ recommendation, is to be performed by authorized
technicians, is covered as a repair for medically necessary equipment which a beneficiary owns. This might include, for
example, breaking down sealed components and performing tests which require specialized testing equipment not
available to the beneficiary.
Replacement
Replacement refers to the provision of an identical or nearly identical item.
Equipment, which the beneficiary owns or is a capped rental item may be replaced in cases of loss or irreparable damage.
Irreparable damage refers to a specific accident or to a natural disaster (e.g. fire, flood, etc.). A physician’s order, when
required, is needed to reaffirm the medical necessity of the item.
Irreparable wear refers to deterioration sustained from day-to-day usage over time and a specific event cannot be
identified. Replacement of the equipment due to irreparable wear takes into consideration the reasonable useful
lifetime of the equipment*. If the item of the equipment has been in continuous use by the patient on either a rental
or purchase basis for the equipment’s useful lifetime, the beneficiary may elect to obtain a new piece of equipment.
Replacement may be reimbursed when a new physician order, when required, is needed to reaffirm the medical necessity
of the item.
Replacement due to wear is not covered during the reasonable useful lifetime of the equipment.
During the reasonable useful lifetime, Medicare does cover repair up to the cost of replacement (but not the actual
replacement) for medically necessary equipment owned by the beneficiary.
Cases suggesting malicious damage, culpable neglect, or wrongful disposition of the equipment should be investigated and
denied where the DMEMAC determines that it is unreasonable to make program payment under the circumstances.
* Reasonable Useful Lifetime
Under no circumstance can the reasonable useful lifetime of the equipment be less than 5 years. Replacement during an
item’s useful lifetime is limited to situations involving loss or irreparable damage from a specific accident or natural
disaster. The useful lifetime of the equipment is based on when the equipment was delivered to the beneficiary, not the
age of the equipment.
Billing for Replacement Parts
When billing option/accessory codes as a replacement, documentation of the medical necessity for the item, make and
model name of the wheelchair base it is being added to and the initial date of service of the wheelchair must be available
to the DME MAC OR PSC on request.
Coding
Replacement parts must be billed with the appropriate HCPCS code that represents the item being replaced, along with the
pricing and informational modifiers required by policy.
Pride Mobility Products Corporation – Product Planning & Reimbursement Center
Repair, Maintenance and Replacement Module – Version 12 (02-2010)
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A replacement option/accessory for a power-operated vehicle (POV) is billed using the most appropriate wheelchair
option/accessory code. All options and accessories provided at the time of initial issue of a POV are not separately billable.
Miscellaneous replacement parts for wheelchairs that do not have a specific HCPCS code and are not included in another
code should be coded K0108. If multiple miscellaneous accessories are provided, each should be billed on separate claim
line using the HCPCS code K0108. When billing more than one line item with HCPCS code K0108, ensure that the
additional information can be matched to the appropriate line item on the claim. It is also helpful to reference the line item
to the submitted charge.
Modifiers
The following modifiers were added to the HCPCS on January 1, 2009, and are effective for claims with dates of service on
or after January 1, 2009:
RA – Replacement of a DME item
RB – Replacement of a part of DME furnished as part of a repair
Modifier “RA” is used for replacement of beneficiary-owned DMEPOS due to loss, irreparable damage, or when the item
has been stolen. Suppliers should also use the RA modifier for billing claims for replacement when the DMEPOS item has
met the reasonable useful lifetime.
Modifier “RB” is used for replacement parts furnished in order to repair beneficiary-owned DMEPOS.
The “RB” modifier applies when an option or accessory is provided either as a replacement for the same part which has
been worn or damaged (e.g. replacing a tire of the same type) or as an upgrade subsequent to providing the wheelchair
base (e.g. replacing a standard seat of a power wheelchair with a power seating system). In both of these situations, the
new item is placed on the existing wheelchair base.
Modifiers such as NU for new, UE for used, KX for necessary information on file, and KE for an item bid under round one of
the DMEPOS competitive bidding program for use with non-competitive bid base equipment, must be used in addition to
the replacement modifier (RA or RB).
If the replacement item is a rebuilt component, the UE (used DME) modifier must be used.
The left (LT) and right (RT) modifiers must be used when appropriate. When the same code for bilateral items (right and
left) is billed on the same date of service, both items must be billed on the same claim line using the RTLT modifiers and 2
units of service.
Claims will be denied for missing information when the modifier is missing or invalid when unnecessary modifiers are used.
Such claims must be resubmitted with the correct information, as this denial does not have appeal rights.
Documentation Requirements
For items provided other than at the time of initial issue of a power wheelchair, there must be a detailed written order
which lists each item that will be separately billed and is signed and dated by the physician. In these situations, the
supplier’s charges and Medicare allowances do not need to be included.
The medical necessity for all options and accessories must be documented in the patient’s medical record and be available
on request. This documentation might include information on why the patient needs the item, the patient’s diagnosis, the
patient’s abilities and limitations as they relate to the equipment (e.g., degree of independence/dependence, frequency
and nature of the activities the patient performs, etc.), the duration of the condition, the expected prognosis, and past
experience using similar equipment.
Billing for Labor
The labor portion of a repair is billed using HCPCS code K0739
K0739
Repair or nonroutine service for durable medical equipment other than oxygen requiring the skill of a technician, labor
component, per 15 minutes.
Payment for any labor involved in the assembling, preparing or modifying the equipment is included in the allowance for
the wheelchair base and accessories and cannot be separately billed.
The payment rates for K0739 include all costs (other than replacement of parts associated with repairing DMEPOS items).
Supplier’s should bill 15 minute increments for the time spent repairing the item and cannot bill for the time spent traveling
to the beneficiary’s home. A supplier may not bill the beneficiary directly for travel charges.
A claim for the code K0739 must include the following information:
The date the equipment was purchased and the make and model (and serial number if available) of the wheelchair
base being repaired. If the exact date of purchase is not available, the month and year of purchase is acceptable.
Medicare will not cover repairs of equipment that was denied by Medicare.
A description of the nature and medical necessity of the repair.
Pride Mobility Products Corporation – Product Planning & Reimbursement Center
Repair, Maintenance and Replacement Module – Version 12 (02-2010)
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An itemization of parts and labor time. (If more than one part is being replaced, the labor time should be broken down
for each part.)
A copy of the manufacturer’s warranty documenting that labor is not covered. (if applicable).
Claims for repairs must include:
• Narrative information itemizing each repair,
• The time taken for each repair.
Temporary Replacement Equipment
One month’s rental of a power wheelchair or power operated vehicle is covered if a patient owned wheelchair or POV is
being repaired. Payment is based on the type of replacement device that is provided but will not exceed the rental
allowance for the power mobility device that is being repaired. Coverage consideration will be given if the patient owned
equipment is covered by Medicare and will not be available for use for more than one day (e.g., if the repair took more
than one day).
Code K0462 – Temporary replacement equipment for patient owned equipment being repaired, any type, is used to bill for
the temporary replacement of patient owned equipment.
A claim for K0462 must include the following information:
Narrative description, manufacturer, and brand name/number of the equipment being repaired,
Date of purchase of the equipment being repaired,
Narrative description, manufacturer name, and brand name/number of the equipment provided as a temporary
replacement,
Description of what was repaired,
Explanation of why the repair took longer than one day.

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