Regulatory Assistance

Unfortunately, regulatory threats and issues are real and can put your business in serious jeopardy.

As a U.S. Rehab member, you will benefit from our team of reimbursement specialists and regulatory experts to keep you updated on new regulations and compliance issues for the DMEPOS industry, competitive bidding, HIPAA, accreditation and other areas.

Our team are not only expert researchers, but also regularly attend industry events. They give you the knowledge and tools you need so that you aren’t facing any regulatory pressure on your own.

Sign up for U.S. Rehab's reimbursement updates via text and never miss an important update again! 

Do you get a lot of email messages regarding reimbursement information? So many that you don't have time to determine which ones are important and which ones are really important? If you miss a truly important update, it can be very detrimental to your business and cost you thousands of dollars in reimbursement. U.S. Rehab has an answer! We've signed up for an EZ Texting program that enables us to send U.S. Rehab members reimbursement updates via text directly to your cell phone. These text messages will contain a brief message of the update with an attachment or a link for details.

Click here for more information!

Hot Issues

CBIC Sends Out Notice to Substantiate Your Bids


From the VGM Competitive Bidding Response Team

We have recently received many calls regarding Connexion’s notice sent out by the CBIC requiring bidders to substantiate their bids. Our team has been in touch with the CBIC liaison regarding some of these concerns. Our initial expectation was that bidders would only receive a letter if the bid was in jeopardy of NOT being “bona fide.”

However, it appears that most or all bidders in the NIV category have received letters regardless of the amount of their bid.

We will keep you updated as to a response from the CBIC.

In the meantime, we are pleased to offer you assistance in responding to the CBIC.

Important: You must respond by Nov. 14 in order to move on to the next step of the bidding evaluation process and not be disqualified.

The Competitive Bid Response Team—consisting of Mark Higley, Ronda Buhrmester, and Craig Douglas—stand ready to assist you with this response to the CBIC.

If you would like to speak to a member of our Competitive Bidding Response Team regarding the bid substantiate letter you received, please click here to fill out the form. A team member will respond to you timely.

Click here to continue reading.

Providers Testify at the 2019 SBA Regulatory Fairness Hearing


In August, the Small Business Administration (SBA) held a Regulatory Fairness Hearing to receive feedback from small business owners about the regulatory environment. Stakeholders that testified on behalf of the DME, CRT, and women’s health industries included Georgie Blackburn of Blackburn’s, John Letizia of Laurel Medical Solutions, Jasmine Jones of Cherry Blossom Intimates, and Nikki Jensen of Essentially Women/VGM.

Click here to read more.



RT and LT Modifier Usage


Instructions for billing right (RT) and left (LT) modifiers: 

When bilateral accessories (2 units) of the same code are billed with the same DOS on the same claim, they must be on separate claim lines. The billing requirement was effective for DOS on or after 3/1/19.

 - Bilateral items not billed on separate claim lines will be returned as unprocessable.

 - Claims returned as unprocessable must be resubmitted.

 - Unprocessable claims do not have appeal rights and cannot be reopened or submitted for adjustment.

Wheelchair Options/Accessories Affected:

E0951, E0952, E0954, E0961, E0967, E0971, E0973, E0974, E0990, E0995, E1009, E1015, E1016, E1017, E1018, E1020, E2205, E2206, E2209, E2211, E2212, E2213, E2216, E2218, E2220, E2224, E2227, E2381, E2382, E2383, E2386, E2388, E2390, E2394, K0015, K0017, K0018, K0019, K0037, K0040, K0041, K0042, K0043, K0044, K0045, K0046, K0047, K0050, K0051, K0052, K0053, K0065, K0069, K0070, K0071, K0072, and K0077

Wheelchair Seating:

E0953, E0956, E1028 (RT/LT modifiers depending on the situation), and K0108 (RT/LT modifiers depending on the situation or item provided)


CMS Adds Seven PMD Codes to the Condition of Payment Prior Authorization


The following seven PMD codes will REQUIRE Prior Authorization NATIONWIDE with DOS on and after July 22, 2019.

Codes: K0857, K0858, K0859, K0860, K0862, K0863, and K0864

These seven codes are currently eligible for ADMC, which is optional. However, come July 22, 2019 (DOS) and after, they will require a Prior Authorization. These codes are being added to the PMDs that were added in 2017 and 2018 (K0813-K0829, K0835-K0856 and K0861).

To learn more, click here.



Mobility Update: RT LT Modifiers & Capped Rental Items


RT LT Modifiers - Effective with DOS 3/1/19, when providing a code that requires the RT LT modifier, they must be billed on two separate lines regardless of if it's a rental or purchase. Use one unit of service on each line, with RT on one line and LT on the other. Codes that required the RT LT modifier are listed as each, where one could be provided in certain circumstances.

Capped Rental Items - Reminder that ALL power wheelchair bases are in the capped rental category. Capped rental can only be rented for up to 13 months, unless they are considered complex rehab (K0835-K0864), and then they have a first month purchase option. This purchase option must be given to the beneficiary and sign and dated in order to bill these items as a purchase (lump sum payment). In addition, all capped rental accessories being used on a complex base (K0835-K0864) also have the first month purchase option.

Example Accessories on Various Wheelchair Bases

E1002 on K0835 - K0864 - Purchase option 
E0955 on K0835 - K0864 - Purchase option 
E0955 on E1161 - RENTAL ONLY
E1028 on E1161 - RENTAL ONLY
E1028 on K0823 - RENTAL ONLY
E1028 on K0835-K0864 - Purchase option


VGM Releases 2019 Reimbursement Rate Guide


VGM is receiving many questions from providers about the 2019 reimbursement rates. This link reviews a summary of changes that occurred or didn’t occur in 2019 and an explanation of the reimbursement rates. Click here for more information.



Newly Released ESRD Final Rule Demonstrates CMS Falls Short on Protecting Patient Access to Medical Equipment 


On November 1, 2018, CMS published the ESRD Final Rule (CMS-1691-F) containing information on Competitive Bidding Program (CBP) reforms and 2019 Medicare payment rates. Upon analysis from industry stakeholders, including NCARTAAHomecare and VGM Government Relations, the final rule issued by CMS, despite several acknowledgments of the current program being highly flawed, is extremely disappointing. CMS’ lack of definitive action does not protect patient accessibility, at least until a new round is set in place.

Click here to read more.

"Hey Dan, Quick Question"


Have you ever had a quick billing and reimbursement question? In this article, U.S. Rehab’s Director of Reimbursement Dan Fedor shares his answers to questions that he is frequently asked.

Some of these questions include:

What is the start date of the order on the DPD supposed to be?
Does the K0835 have a purchase option? Since it’s a capped rental, is it rental only?
How do I calculate the purchase allowable on a complex rehab power chair and for the capped rental accessories?

To read more, click here.


Say Goodbye to KH!


The KH modifier was required in the first month for a capped rental item. Well, say goodbye to the KH modifier when a capped rental item is paid as a lump sum/purchase for dates of service on and after Oct. 1, 2018! 

This applies to initial issue items, such as K0835-K0864 complex power wheelchair bases and the related capped rental accessories used on those bases, as well as repair parts paid as a lump sum. Click here to view a few examples of common codes and to read more.


Important Reminders for Reimbursement Updates 


1. No KH On Purchased Capped Rentals Beginning October 1, 2018 

2. Power Mobility Device (PMD) Prior Authorization Extended And Expanded Nationally As Of Sept. 1, 2018

3. Sign Up For Reimbursement Updates Via Text Message

For more information regarding these updates, please click here.

Power Wheelchair Prior Authorization - Update 


CMS has selected 31 items of durable medical equipment (K0813-K0855) to be subject to required prior authorization beginning NATIONWIDE on Sept. 1, 2018. 

All new rental series claims (K0813-K0831) for these PMDs with a date of delivery on or after Sept. 1, 2018, must be associated with a prior authorization request as a condition of payment. Those that have the purchase option (K0835-K0855) will also require a prior authorization as a condition of payment. Click here for more information!

The KE Modifier is Back (Temporarily)!

June 5, 2018

The KE modifier is BACK temporarily!

The DME MACs published the following article on May 31, 2018 regarding the KE modifier. If you provide manual wheelchairs to Medicare beneficiaries that reside in a rural area, then please continue reading.

If you provide an affected accessory on a manual wheelchair base (K0001-K0009 and E1161) to a Medicare beneficiary who resides in a rural area (based on zip code) and the date of service is from June 1, 2018 – Dec 31, 2018, then you should append the KE modifier on those accessories. The purpose of the KE modifier is to receive the highest reimbursement possible for those accessories.

Click here for more details.



Power Mobility Device (PMD) Prior Authorization Extended and Expanded Nationally!

June 4, 2018

The PMD Prior Authorization Demo program was established in 2012 in seven states and was expanded to an additional 12 states in Oct 2014. This demo program was slated to end on Aug 31, 2018, however, prior authorization for certain PMDs will continue and be expanded nationally beginning Sept 1, 2018 as a Condition of Payment.

Click here to learn more details about the extension here.



Revalidation Reminder

March 14, 2018 

The revalidation reminder link is available for suppliers to check if their revalidation is due this year. REMEMBER that the National Supplier Clearinghouse (NSC) will send you a letter prior to the due date. Do not submit any information until you receive the letter.

Click here for more information.



CGS Update: Custom Cushion and Backs REVERT BACK to Individual Pricing!

May 23, 2017

In April of 2017, DME MACs B and C (GCS) decided to establish a fee for the custom cushion and back codes (E2609 and E2617, respectively) without notifying the provider community. Because these items are custom (misc.), they were manually priced under individual consideration prior to this change. The fees they established were a significant reduction (60 percent lower) than previously priced claims.

The CRT industry strongly voiced concern with this change, and as a result, CGS has decided to revert back to individual consideration pricing for these codes! Read more.


Providing Solutions for Complex Rehab Providers