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Complex Rehab Repair FAQs

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Clarify the terms "repair" and "replacement". Does the 5-year reasonable useful lifetime rule apply to replacement parts used to repair DME (such as tires and batteries)?
- Repair means to fix or mend. During the course of a repair, parts or components of a base item may be replaced. The replacement of parts or components that make up a base item is considered a repair. When the base item is completely replaced with a new base item, then that is considered a "replacement." The default 5-year reasonable useful lifetime applies to replacement of the base item, not to parts and accessories.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
How often can tires, batteries, etc. be replaced? If the claim denies for frequency limitations, does the supplier get a PR (patient responsibility) denial or a CO (contractual obligation) denial?
- No routine or prophylactic replacement is appropriate. Wear items such as batteries and tires are eligible for replacement as a repair to a wheelchair only when they become non-functional. Because the frequency of necessary replacement can vary so much depending on how an individual beneficiary uses his/her wheelchair, it is difficult to set a "usual" replacement frequency. Suppliers should maintain records documenting the need for the repair. Repairs are covered under Medicare only when made to medically necessary equipment. Thus, denials associated with repairs are considered "medical necessity" denials, which get a CO message unless an ABN has been obtained.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
What are the requirements for repairs to equipment not purchased by Medicare?
- CMS requirements are located in IOM 100-2, Ch. 15, §110.2 The requirement states:
  
  "Payment may be made for repair, maintenance, and replacement of medically required DME, including equipment which had been in use before the user enrolled in Part B of the program."
  
  Key to implementing this provision is in understanding the criteria that the equipment is "medically required DME." The criteria means that all of the applicable benefit category and reasonable and necessary requirements for the base item must be met before the item is eligible to have repairs reimbursed. These criteria are generally found in the relevant local coverage determination (LCD).
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
When repairs are made to equipment by a supplier who did not sell the equipment to the client, it is often difficult to get the correct date of purchase and HCPCS code. Although the repair supplier can verify through the myCGS portal and/or the IVR if Medicare paid a claim, that supplier does not know if the original supplier had the proper documentation and was paid properly. Is there a way the repair supplier can be protected?
- When reviewing DMEPOS claims for repairs, contractors are not required to determine that the requirements for provision of the DMEPOS item as when it was originally ordered were met. However, there must be documentation from the physician or treating practitioner indicating the item being repaired continues to be medically necessary. For this purpose, documentation is considered timely when it is on record in the preceding 12 months.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
Should a replacement drive wheel for a power mobility device be billed using individual codes (for the wheel, tire, and appropriate tube or insert) since there is no HCPCS code for a complete power wheel? Or should HCPCS K0108 be used for the entire assembly?
- In the situation described, it would be appropriate to use the codes for the individual components.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
HCPCS code K0462 (temporary replacement for patient-owned equipment being repaired, any type) is used when a supplier provides a complete wheelchair to a beneficiary on a temporary basis if his/her wheelchair requires major repair (such as taking more than one day). Rehab power wheelchairs include sophisticated seating systems and advanced electronics that are highly individualized for the beneficiary. Providing a similar loaner wheelchair is not possible. If a supplier is able to substitute a temporary replacement component while the beneficiary's item is being repaired, can K0462 be used?
- Use of HCPCS code K0462 for temporary replacement is applicable when an appropriate complete item is provided or when swapping out individual components while leaving the beneficiary's base equipment in place as described in the scenario above. Suppliers should maintain detailed records describing the nature of the repair and the justification for the temporary replacement of the item should be maintained. The following must be included in the Narrative Section of the claim for K0462:
  1. HCPCS code, or manufacturer and brand name/number of the equipment being repaired, with date of purchase
  2. A narrative description and manufacturer and brand name/number of the replacement equipment
  3. A description of what was repaired
  4. A description of why the repair took more than one day to complete
  Originally published: 02.20.17
  Reviewed: 12.06.23
With modifiers RA and RB, is it correct to say that the RA modifier would only be used when replacing a full piece of equipment, such as a full wheelchair, which is over 5 years old or is being replaced due to a condition change?
- For wheelchairs, the RA modifier is used for replacement of the complete item which has been lost, stolen, or irreparably damaged. The RA modifier is not used when new equipment is provided due to a change in medical condition.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
If a beneficiary refuses to bring their equipment to the supplier location, can they be charged a fee for this service?
- Medicare's payment for repairs (in other words, parts and labor) is all-inclusive. There is no separate payment for delivery or service charges except in very limited circumstances as outlined in IOM 100-4, Ch. 20, §60.
  Originally published: 02.20.17
  Reviewed: 12.06.23
The reasonable useful lifetime for durable medical equipment is 5 years. If an item that is less than 5 years old needs to be repaired because of "wear and tear" (rather than a specific incident), and a thorough evaluation reveals that the cost to repair the equipment exceeds the cost to replace the equipment, would Medicare consider payment for a replacement piece of equipment?
- No, according to Medicare statute, during an item's reasonable useful lifetime, payment can only be made for repairs due to wear and tear up to the cost of replacement (but not actual replacement). Replacement of equipment due to irreparable wear takes into consideration the reasonable useful lifetime of the equipment.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
If the equipment has been repaired on several different occasions, is in need of repair again, and no single repair has exceeded the cost to replace the equipment but the cumulative repair costs will exceed the replacement cost, would Medicare consider payment for a replacement piece of equipment?
- No, according to Medicare statute, during an item's reasonable useful lifetime, payment can only be made for repairs up to the cost of replacement.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
What percentage of repair to replacement cost would Medicare consider acceptable to deem the purchase of a replacement item more cost effective?
- There is no provision for replacement due to "wear and tear" prior to the end of the item's useful lifetime.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23
Is the reasonable useful lifetime of an item based on the age of the equipment?
- No. Computation of the reasonable useful lifetime is based on when the equipment is delivered to the beneficiary, not the actual age of the equipment.
  
  Originally published: 02.20.17
  Reviewed: 12.06.23

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