In October DHCS announced some changes to a variety of wheelchair parts and accessories. Some of the changes did not seem to be based on 100% of the current Medicare allowables which is the current reimbursement methodology for custom rehab equipment and accessories. CAMPS reached out to the Rate Development Branch and asked for a review and clarification. After several months of back and forth the revised allowables, pasted below, were provided to us. Those rates will not be in the system for another 90 days, but the rates will be retroactive to October 1, 2017 when the previous rate changes were implemented. Those corrected payment will be made at some point in the future via EPC and providers do not need to resubmit the impacted claims.

 

While the changes are welcome these rates do not reflect what Medicare allows when some of these codes are billed with a KU modifier reflecting the higher cost of accessories and installation when they are used in a Power Group 3 or higher complex rehab wheelchair. We continue to push DHCS to recognize the difference in Medicare reimbursement when the KU modifier is included.

Procedure Codes	Description	New Medi-Cal Purchase Rate (NU)	New Medi-Cal Rental Rate (RR)
E0140	Walker w/ Trunk Support	$210.56	$21.06
E0149	HD Walker w/ Wheels	$95.28	$9.53
E0197	App Pad	No Change	$13.50
K0015	Detach, Nonadjust Height Armrest, Each	No Change	$10.77
E0955	Cushioned Headrest	$133.70	$13.37
E0985	W/C Seat Lift Mechanism	$194.40	No Change
E1020	Residual Limb Support System	$168.60	No Change
E0995	Wheelchair Calf Rest	$24.94	$2.49
K0042	Standard Size Footplate, Each	$29.03	$2.90
K0043	Footrest, Lower Extension Tube, Each	$17.92	$1.79
K0044	Footrest, Upper Hanger, Br	$15.59	$1.56
K0045	Footrest, Complete Assembly	$51.28	$5.13
K0046	Elevating Legrest, Lower Ext Tube, Each	$18.04	$1.80
K0047	Elevating Legrest, Upper Hanger, Br	$63.74	$6.37
K0050	Ratchet Assembly	$29.57	$2.96
K0051	Cam Release Assy, Footrest or Legrest, Ea	$46.78	$4.68
K0052	Swingaway, Detachable Foot	$65.40	$6.54
E0967	Manual WC Hand Rim w Project	$65.23	$6.52
E2206	Complete Wheel Lock Assembly	$35.26	$3.53
E2220	Solid Propulsion Tire Each	$26.61	$2.66
E2221	Solid Caster Tire Each	$23.84	$2.38
E2222	Solid Caster Integrated Whl	$19.86	$1.99
E2224	Propulsion Whl Excludes T	$81.48	$8.15
E2228	MWC Acc, Wheelchair Brake	$865.90	$86.59
E2368	Pwr WC Drivewheel Motor Repl	$379.50	$37.95
E2369	Pwr WC Drivewheel Gear Repl	$358.60	$35.86
E2370	Pwr WC Drwh Motor/Gear Comb	$493.20	$49.32
K0098	Drive Belt for Power Wheelchair	$16.92	$1.70
E2375	Non-Expandable Controller	$602.20	$60.22
K0070	Rear Wheel, Assy, Comp w/Pneumatic Tire, S	$146.10	$14.61
E1028	W/C Manual Swingaway	$127.10	$12.71
K0071	Front Caster Assy, Comp w/Pneumatic Tire	$98.30	$9.83
K0072	Front Caster Assy, Comp, w/Semipneumatic	$61.00	$6.10
K0073	Caster Pin Lock, Each	$31.60	$3.16
K0077	Front Caster Assy, Comp, w/Solid Tire, Eac	$50.40	$5.04

CAMPS continues to participate in a DHCS Stakeholder Group on implementation of the federal requirement for ordering/rendering providers. Medi-Cal is required to verify that any physician or other practitioner who orders services for a Medi-Cal enrollee is either enrolled in Medi-Cal or Medicare and has valid Type 1 or individual NPI number. When implemented a DME provider who bills for services ordered by a practitioner without a valid NPI will have that claim denied.  Medi-Cal has been providing sample denial codes to DME providers to highlight a prescriber who is not properly enrolled but has not been denying claims, i.e. informational only.

 

The first provider type being impacted is pharmacy but still in an informational mode without claim denial. In a recent stakeholder call the following updates were provided;

• DHCS intends to make the effective date of enrollment for an approved ORP provider one year prior to the date DHCS received the enrollment application.
• The State believes this will ease the burden on billing providers once they implement the edits to deny claims.
• PED believes there are still many ordering providers who are not yet enrolled.
• There is still no date of implementation of a denial edit and providers will be noticed at least 90-days in advance.
• Provider enrollment (PE) wants providers and associations to continue reaching out to ORPs that have been flagged with RAD code 0558 and tell them to enroll.
• PED wants providers to send them examples of the ORP Validation Tool not working properly.

The Provider Enrollment Division (PED) is seeking providers to help test Release 3.0 of the Provider Application and Validation for Enrollment (PAVE) system, our online resource for enrolling Medi-Cal providers. Providers, credentialers, administrators, billers, or others who complete Medi-Cal provider applications are eligible to help us test the next release of PAVE.

 

Testing will last for approximately two weeks. All testing activities are completed at your location. Testers can expect to spend an average of 1-2 hours per day on testing activities. No experience is necessary. Training, daily guidance and technical assistance will be provided.

 

We are currently compiling an interest list of those who wish to participate. Dates and additional details will available as we get closer to testing.

 

To add your name to our interest list, please complete our electronic form.