The Centers for Medicare & Medicaid Services (CMS) has released a crucial update through Change Request (CR) 13610, effective July 8, 2024. This update provides detailed instructions for processing claims related to the replacement of power or manual wheelchairs when the original manufacturer exits the wheelchair business. This scenario has become increasingly relevant as manufacturers discontinue products or cease operations, leaving beneficiaries without access to necessary repair parts or replacement equipment.

Key Points of CR 13610:

1. Manufacturer Exit Scenarios

This update addresses situations where a wheelchair manufacturer discontinues operations—whether through business closure or bankruptcy—resulting in the wheelchair no longer being available on the market. When aftermarket parts are unavailable, making the existing equipment inoperable, beneficiaries may need to replace their wheelchairs entirely. This update allows Medicare to consider such equipment as “lost” under federal regulations, thus permitting the issuance of replacement equipment.

2. Replacement Equipment and Claims Processing

Under the new guidelines, when a manufacturer exits the business and no aftermarket parts are available, Durable Medical Equipment (DME) suppliers can process claims for replacement wheelchairs. Suppliers must include the appropriate Healthcare Common Procedure Coding System (HCPCS) code for the replacement equipment along with specific HCPCS modifiers such as RA (Replacement of a DME Item) and KH (Initial Claim, Purchase, or First Month Rental) when applicable. This ensures that the claim is processed correctly and the replacement equipment is provided under the new 13-month capped rental period, starting from the date the new equipment is furnished.

3. Prior Authorization Requirements

Suppliers are required to submit a Prior Authorization Request (PAR) before furnishing the new wheelchair to the beneficiary and submitting a claim for processing. This step is crucial to ensure that the replacement equipment meets Medicare coverage criteria and that the claim will be reimbursed. Suppliers must include a narrative stating that the replacement is due to the manufacturer exiting the business, which should be submitted through the proper electronic claim formats or noted on the CMS-1500 claim form.

4. Exemptions and Clarifications

It’s important to note that this replacement policy does not apply if repair parts are available from sources other than the original manufacturer. The policy also does not apply if the wheelchair does not yet require repairs or replacement parts. Suppliers must ensure that these conditions are met before processing a replacement claim under this new directive.

Impact on Beneficiaries and Providers

This update is significant for both beneficiaries who rely on power or manual wheelchairs and the providers who supply and maintain this equipment. By allowing for the replacement of wheelchairs when the manufacturer exits the market and no parts are available, CMS is ensuring that beneficiaries continue to have access to the mobility aids they need. For providers, this update clarifies the process for submitting claims in these specific circumstances, helping to avoid claim denials and ensuring timely reimbursement.

Conclusion

CMS’s CR 13610 provides clear and essential guidance for managing the replacement of wheelchair equipment in scenarios where the manufacturer exits the business. By adhering to these guidelines, DME suppliers can ensure compliance with Medicare requirements while continuing to meet the needs of their patients.

For more detailed information and to stay updated on further changes, DME suppliers should consult the official CMS documentation or contact their Medicare Administrative Contractor (MAC).