Section 182-543-9200. Reimbursement method—Wheelchairs.

(1) The agency reimburses a DME provider for purchased wheelchairs based on the assigned health care common procedure coding system (HCPCS) code. The agency requires providers to make sure the specific brand and model of wheelchairs dispensed are coded according to the Centers for Medicare and Medicaid Services' (CMS) pricing, data analysis, and coding (PDAC) web site.

(2) The agency sets, evaluates and updates the maximum allowable fees at least once yearly for wheelchair purchases and wheelchair rentals using the lesser of the following:

(a) The current medicare fees;

(b) A pricing cluster; or

(c) On a by-report (BR) basis.

(3) Establishing reimbursement rates for purchased wheelchairs based on pricing clusters.

(a) A pricing cluster is based on a specific health care common procedure coding system (HCPCS) code.

(b) The agency's pricing cluster is made up of all the brands/models for which the agency obtains pricing information. However, the agency may limit the number of brands/models included in the pricing cluster. The agency considers all of the following when establishing a pricing cluster:

(i) A client's medical needs;

(ii) Product quality;

(iii) Introduction, substitution or discontinuation of certain brands/models; and

(iv) Cost.

(c) When establishing the fee for wheelchair items in a pricing cluster, the maximum allowable fee is the median amount of available manufacturers' list prices for all brands/models as noted in (b) of this subsection.

(4) The agency evaluates a BR item, procedure, or service for medical necessity, appropriateness and reimbursement value on a case-by-case basis. The agency calculates the reimbursement rate for these items at a percentage of the manufacturer's list or manufacturer's suggested retail price (MSRP) as of January 31st of the base year, or a percentage of the wholesale acquisition cost (AC). The agency uses the following percentages:

(a) For basic standard wheelchairs, sixty-five percent of MSRP or one hundred forty percent of AC;

(b) For parts, eighty-four percent of MSRP or one hundred forty percent of AC;

(c) For seat and back cushions, eighty percent of MSRP or one hundred forty percent of AC.

(5) The agency may adopt policies, procedure codes, and/or rates that are inconsistent with those set by medicare if the agency determines that such actions are necessary.

[Statutory Authority: RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-9200, filed 3/25/14, effective 4/25/14. Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-543-9200, filed 7/30/12, effective 8/30/12; WSR 12-07-022, § 182-543-9200, filed 3/12/12, effective 4/12/12. WSR 11-14-075, recodified as § 182-543-9200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-9200, filed 6/29/11, effective 8/1/11.]

RCW 41.05.021 and 2013 c 178. WSR 14-08-035, § 182-543-9200, filed 3/25/14, effective 4/25/14. Statutory Authority: RCW 41.05.021. WSR 12-16-059, § 182-543-9200, filed 7/30/12, effective 8/30/12; WSR 12-07-022, § 182-543-9200, filed 3/12/12, effective 4/12/12. WSR 11-14-075, recodified as § 182-543-9200, filed 6/30/11, effective 7/1/11. Statutory Authority: RCW 74.08.090 and 74.04.050. WSR 11-14-052, § 388-543-9200, filed 6/29/11, effective 8/1/11.