Complex rehab: Let’s reconsider miscellaneous codes

Q. How do HCPCS codes impact access? 

The purpose of miscellaneous HCPCS codes such as K0108 wheelchair component or accessory, not otherwise specified, and E1399 durable medical equipment, miscellaneous, is to facilitate billing of items infrequently provided and when no defined HCPCS code describes the item. The two aforementioned codes were made effective Oct. 1, 1993.  

Miscellaneous codes have served their initial purpose, but over the last 30 years, they have become problematic. Claims submitted containing miscellaneous codes must be manually reviewed for coverage and payment. Some payers lack the capacity to verify whether the use of a miscellaneous code is appropriate or whether a defined code should be used. The code used, ultimately, impacts the amount of reimbursement, so verifying the HCPCS code is critical. This is the tension causing the current environment regarding miscellaneous codes.  

In 2015, the CMS proposed the creation of new HCPCS codes to split K0108 and E1399 into: 

• inexpensive DME; 

• other DME or expensive DME; and 

• replacement parts for DME being repaired. 

The following HCPCS codes would replace codes E1399 and K0108, for Medicare claims processing purposes: 

• KXXX1 durable medical equipment, miscellaneous, the purchase price does not exceed $150; 

• KXXX2 durable medical equipment, miscellaneous, the purchase price exceeds $150; 

• KXXX3 wheelchair component or accessory, miscellaneous, the purchase price does not exceed $150; 

• KXXX4 wheelchair component or accessory, miscellaneous, the purchase price exceeds $150;  

• KXXX5 repair part for use with beneficiary owned durable medical equipment, other than wheelchair, not covered under supplier or manufacturer warranty, not otherwise specified; and 

• KXXX6 repair part for use with beneficiary owned wheelchair, not covered under supplier or manufacturer warranty.  

After receiving comments regarding the proposal, CMS withdrew it. Given the increasing issues associated with HCPCS codes, and miscellaneous codes in particular, a new code set for billing the myriad items not represented by the existing defined code set may be worthy of reconsideration. 

Rita Stanley is principal and policy consultant at Merriman Innovation Consulting. Reach her at rita.stanley@merrimaninnovation.com.