Appendix C
Medicare Data
METHODS
This study was a secondary analysis of Medicare claims data for the calendar years 2013-2014. We used a 5 percent random sample of Medicare beneficiaries’ claims data that is available at the University of Texas Medical Branch, in the Research Identifiable Format, for those years.
Study Sample Population
The study sample population comprised all Medicare beneficiaries, irrespective of the type of plan (e.g., traditional fee-for-service or Medicare Advantage) in which they were enrolled during the study period. However, we selected only those beneficiaries aged 20 to 67 years so the sample would be representative of the beneficiaries of the U.S. Social Security Administration. No other inclusion/exclusion criterion were used for deriving the study sample cohort.
Data Sources and Characteristics
For this study, we used data from two data files that are part of the Medicare claims data resources. Detailed descriptions of these data files are provided in Table C-1.
TABLE C-1
Description of Data Files
| Data File | Years | Description |
|---|---|---|
| Durable Medical Equipment (DME) | 2013–2014 |
Two DME data files were used: the DME claim line file and the DME claims file. (For additional information related to these files, see ResDAC, n.d.-b.)
|
| Master Beneficiary Summary File (MBSF) | 2013–2014 | The MBSF comprised individual-level characteristics such as age, gender, race/ethnicity, disability status, Medicare/Medicaid dual eligibility status, and Medicare Advantage participation. (For additional information related to these files, see ResDAC, n.d.-d.) |
Data Extraction and Management Process
The primary criterion for selection of cases for this study was type of durable medical equipment (DME). We targeted three broad categories of DME: wheeled and seated mobility devices (WSMDs), speech-generating devices (SGDs), and upper-extremity prostheses (UEPs). We constructed three separate datasets comprising these DME categories. The data extraction for each type of DME was based on a combination of the Berenson-Eggers type of service (BETOS) codes and the Health Care Common Procedure Coding System (HCPCS) level II alphanumeric codes:
- BETOS codes were developed as a way to categorize the types of services provided to Medicare beneficiaries. There are seven categories for these codes: evaluation and management, procedures, imaging, tests, DME, other, and exception/unclassified. For example, BETOS codes for WSMDs are in the DME category. Table C-2 provides a detailed list of the BETOS codes (CMS, n.d.).
- The HCPCS is a combination of codes that indicate services, procedures, or products (e.g., DME) provided to Medicare beneficiaries or to individuals under other health plans (including private insurance). There are three levels of HCPCS codes. For this study, we utilized HCPCS level II alphanumeric codes to identify and define the types of DME that were provided. Tables C-3, C-4, and C-5,
respectively, list HCPCS level II alphanumeric codes associated with the WSMD, UEP, and SGD groups (ResDAC, n.d.-c).
After constructing the product database, we linked it with the Master Beneficiary Summary File (MBSF) to obtain sociodemographic and clinical characteristics (including diagnosis codes) and state of residence for individuals in these three categories who received DME. All the individual-level sociodemographic characteristics were extracted from the MBSF:
- For age we used four categories: 20-45, 46-55, 56-64, and 65-67.
- Gender was classified as male or female.
- Race/ethnicity was divided into white, black, Hispanic, and other.
- For Medicare Advantage enrollment, we determined the number of months a person was covered under Medicare health maintenance organization (HMO) plans, and those with “no” Medicare HMO enrollment for that year were classified as Medicare fee-for-service.
For classification of International Classification of Diseases, Ninth Revision (ICD-9) codes into diagnostic categories, we used a method suggested by the Centers for Medicare & Medicaid Services (CMS) as part of its release of public-use files for DME. Using that method, we could classify ICD-9 codes associated with provision of WSMDs, SGDs, and UEPs into such categories as diseases of the nervous system, diseases of the circulatory system, and diseases of the musculoskeletal system and connective tissue, among others. Table C-6 provides a full list of the ICD-9 codes and their
TABLE C-2
Berenson-Eggers Type of Service Codes: Durable Medical Equipment
| Code | Service |
|---|---|
| D1A | Medical/surgical supplies |
| D1B | Hospital beds |
| D1C | Oxygen and supplies |
| D1D | Wheelchairs |
| D1E | Other Durable Medical Equipment |
| D1F | Prosthetic/orthotic devices |
| D1G | Drugs administered through Durable Medical Equipment |
SOURCE: ResDAC, n.d.-a.
| HCPCS Code | Description |
|---|---|
| E0983 | Manual wheelchair accessory, power add-on to convert manual wheelchair to motorized wheelchair, joystick control |
| E0986 | Manual wheelchair accessory, push-rim activated power assist system |
| E1038 | Transport chair, adult size, patient weight capacity up to and including 300 pounds |
| E1039 | Transport chair, adult size, heavy-duty, patient weight capacity greater than 300 pounds |
| E1088 | High-strength, lightweight wheelchair, detachable arms desk or full length, swing-away detachable elevating leg rests |
| E1130 | Standard wheelchair, fixed full-length arms, fixed or swing-away detachable footrests |
| E1140 | Wheelchair, detachable arms, desk or full length, swing-away detachable footrests |
| E1161 | Manual adult-size wheelchair, includes tilt in space |
| K0001 | Standard wheelchair |
| K0002 | Standard hemi (low-seat) wheelchair |
| K0003 | Lightweight wheelchair |
| K0004 | High-strength, lightweight wheelchair |
| K0005 | Ultralightweight wheelchair |
| K0006 | Heavy-duty wheelchair |
| K0007 | Extra-heavy-duty wheelchair |
| K0009 | Other manual wheelchair/base |
| K0011 | Standard—weight frame motorized/power wheelchair with programmable control parameters for speed adjustment, tremor dampening, acceleration control, and braking |
| K0014 | Other motorized/power wheelchair base |
| K0800 | Power-operated vehicle, group 1 standard, patient weight capacity up to and including 300 pounds |
| K0801 | Power-operated vehicle, group 1 heavy-duty, patient weight capacity 301 to 450 pounds |
| K0802 | Power-operated vehicle, group 1 very-heavy-duty, patient weight capacity 451 to 600 pounds |
| K0806 | Power-operated vehicle, group 2 standard, patient weight capacity up to and including 300 pounds |
| K0807 | Power-operated vehicle, group 2 heavy-duty, patient weight capacity 301 to 450 pounds |
| HCPCS Code | Description |
|---|---|
| K0808 | Power-operated vehicle, group 2 very-heavy-duty, patient weight capacity 451 to 600 pounds |
| K0814 | Power wheelchair, group 1 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
| K0815 | Power wheelchair, group 1 standard, sling/solid seat and back, patient weight capacity up to and including 300 pounds |
| K0816 | Power wheelchair, group 1 standard, captains chair, patient weight capacity up to and including 300 pounds |
| K0820 | Power wheelchair, group 2 standard, portable, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0821 | Power wheelchair, group 2 standard, portable, captains chair, patient weight capacity up to and including 300 pounds |
| K0822 | Power wheelchair, group 2 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0823 | Power wheelchair, group 2 standard, captains chair, patient weight capacity up to and including 300 pounds |
| K0824 | Power wheelchair, group 2 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0825 | Power wheelchair, group 2 heavy-duty, captains chair, patient weight capacity 301 to 450 pounds |
| K0826 | Power wheelchair, group 2 very-heavy-duty, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0827 | Power wheelchair, group 2 very-heavy-duty, captains chair, patient weight capacity 451 to 600 pounds |
| K0829 | Power wheelchair, group 2 extra-heavy-duty, captains chair, patient weight 601 pounds or more |
| K0835 | Power wheelchair, group 2 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0837 | Power wheelchair, group 2 heavy-duty, single power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0838 | Power wheelchair, group 2 very-heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0839 | Power wheelchair, group 2 very-heavy-duty, single power option sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0840 | Power wheelchair, group 2 extra-heavy-duty, single power option, sling/solid seat/back, patient weight capacity 601 pounds or more |
| K0841 | Power wheelchair, group 2 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0843 | Power wheelchair, group 2 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| HCPCS Code | Description |
|---|---|
| K0848 | Power wheelchair, group 3 standard, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0849 | Power wheelchair, group 3 standard, captains chair, patient weight capacity up to and including 300 pounds |
| K0850 | Power wheelchair, group 3 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0851 | Power wheelchair, group 3 heavy-duty, captains chair, patient weight capacity 301 to 450 pounds |
| K0853 | Power wheelchair, group 3 very-heavy-duty, captains chair, patient weight capacity 451 to 600 pounds |
| K0854 | Power wheelchair, group 3 extra-heavy-duty, sling/solid seat/back, patient weight capacity 601 pounds or more |
| K0855 | Power wheelchair, group 3 extra-heavy-duty, captains chair, patient weight capacity 601 pounds or more |
| K0856 | Power wheelchair, group 3 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0857 | Power wheelchair, group 3 standard, single power option, captains chair, patient weight capacity up to and including 300 pounds |
| K0858 | Power wheelchair, group 3 heavy-duty, single power option, sling/solid seat/back, patient weight 301 to 450 pounds |
| K0860 | Power wheelchair, group 3 very-heavy-duty, single power option, sling/solid seat/back, patient weight capacity 451 to 600 pounds |
| K0861 | Power wheelchair, group 3 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0862 | Power wheelchair, group 3 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0870 | Power wheelchair, group 4 heavy-duty, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
| K0877 | Power wheelchair, group 4 standard, single power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0880 | Power wheelchair, group 4 very-heavy-duty, single power option, sling/solid seat/back, patient weight 451 to 600 pounds |
| K0884 | Power wheelchair, group 4 standard, multiple power option, sling/solid seat/back, patient weight capacity up to and including 300 pounds |
| K0886 | Power wheelchair, group 4 heavy-duty, multiple power option, sling/solid seat/back, patient weight capacity 301 to 450 pounds |
SOURCE: CMS, 2016.
TABLE C-4
Healthcare Common Procedure Coding System (HCPCS) Codes for Upper-Extremity Prostheses
| Prosthetic Devices | HCPCS Codes |
|---|---|
| Body-Powered Devices | ‘L6620’ ‘L6621’ ‘L6623’ ‘L6624’ ‘L6625’ ‘L6637’ ‘L6640’ ‘L6641’ ‘L6642’ ‘L6645’ ‘L6646’ ‘L6647’ ‘L6799’ ‘L6700’ ‘L6704’ ‘L6705’ ‘L6706’ ‘L6707’ ‘L6708’ ‘L6709’ ‘L6710’ ‘L6711’ ‘L6712’ ‘L6713’ ‘L6714’ ‘L6720’ ‘L6721’ ‘L6722’ ‘L6723’ ‘L6725’ ‘L6730’ ‘L6804’ ‘L6845’ ‘L6850’ ‘L6855’ ‘L6860’ ‘L6865’ ‘L6867’ ‘L6868’ ‘L6870’ ‘L6872’ ‘L6873’ ‘L6875’ ‘L7610’ ‘L7611’ ‘L7612’ ‘L7613’ ‘L7614’ ‘L7621’ ‘L7622’ |
| Myoelectric Devices | ‘L6611’ ‘L6621’ ‘L6628’ ‘L6629’ ‘L6638’ ‘L6648’ ‘L6681’ ‘L6682’ ‘L6881’ ‘L6882’ ‘L6920’ ‘L6925’ ‘L6930’ ‘L6935’ ‘L6940’ ‘L6945’ ‘L6950’ ‘L6955’ ‘L6960’ ‘L6965’ ‘L6970’ ‘L6975’ ‘L7007’ ‘L7008’ ‘L7009’ ‘L7040’ ‘L7045’ ‘L7170’ ‘L7180’ ‘L7181’ ‘L7185’ ‘L7186’ ‘L7190’ ‘L7191’ ‘L7260’ ‘L7261’ ‘L7360’ ‘L7362’ ‘L7364’ ‘L7366’ ‘L7367’ ‘L7368’ |
| Other | NA |
NOTE: NA = not applicable.
SOURCE: Etter et al., 2015.
TABLE C-5
Healthcare Common Procedure Coding System (HCPCS) Codes for Speech-Generating Devices
| Speech-Generating Device | HCPCS Code |
|---|---|
| Speech-generating device, digitized speech, using prerecorded messages, greater than 8 minutes but less than or equal to 20 minutes recording time | E2502 |
| Speech-generating device, synthesized speech, permitting multiple methods of message formulation and device access | E2510 |
SOURCE: ASHA, n.d.
classification in these diagnosis categories, while Table C-7 lists the ICD-9 codes associated with the distribution of diagnosis categories for upper-extremity amputation.
DATA LIMITATIONS
The data used for this study were Medicare claims for the years 2013-2014. These data are “claims processing” data and not typically intended
| Diagnostic Category | ICD-9 Codes |
|---|---|
| Infectious and parasitic diseases | 001–139 |
| Neoplasms | 140–239 |
| Endocrine, nutritional, and metabolic diseases and immunity disorders | 240–279 |
| Diseases of the blood and blood-forming organs | 280–289 |
| Mental disorders | 290–319 |
| Diseases of the nervous system | 320–359 |
| Diseases of the sense organs | 360–389 |
| Diseases of the circulatory system | 390–459 |
| Diseases of the respiratory system | 460–519 |
| Diseases of the digestive system | 520–579 |
| Diseases of the genitourinary system | 580–629 |
| Complications of pregnancy, childbirth, and the puerperium | 630–679 |
| Diseases of the skin and subcutaneous tissue | 680–709 |
| Diseases of the musculoskeletal system and connective tissue | 710–739 |
| Congenital anomalies | 740–759 |
| Certain conditions originating in the perinatal period | 760–779 |
| Symptoms, signs, and ill-defined conditions | 780–799 |
| Injury and poisoning | 800–999 |
| External causes of injury and supplemental classification | E and V codes |
| Mental disorders | 290–319 |
SOURCE: CMS, 2010.
for use in research studies. They lack the information necessary for creating a health/disability profile of patients to match with the types of DME that were prescribed. Thus, the information presented in this report cannot be used to determine the appropriateness of the provision of DME. In addition, the data are based on a random 5 percent sample of Medicare beneficiaries. That sample yielded a small study sample for the SGD and UEP groups, which limited the presentation of granular information based on individual-level characteristics. In future analyses, use of a 20 percent random sample and/or more years of data is needed. The age criterion used for selection of the study cohort (ages 20-67 years) also is underrepresented in Medicare claims data. This is another reason for the small study sample
| Amputation Category | ICD-9 Codes |
|---|---|
| Below Elbow | ‘8870’ ‘8871’ ‘V4965’ ‘24930’ ‘25900’ ‘25905’ ‘25907’ ‘25909’ ‘25915’ ‘8405’ ‘V4963’ ‘25927’ ‘25931’ ‘8403’ ‘V4964’ ‘25920’ ‘25924’ ‘8404’ |
| Above Elbow | ‘8872’ ‘8873’ ‘8406’ ‘V4966’ ‘24900’ ‘24920’ ‘24925’ ‘24931’ ‘24935’ ‘24940’ ‘8407’ |
| Level/Side Unspecified | ‘8874’ ‘8875’ ‘8876’ ‘8877’ ‘V4960’ ‘V520’ ‘V528’ |
| Thumb/Finger | ‘885’ ‘8850’ ‘8851’ ‘886’ ‘8860’ ‘8861’ ‘V4961’ ‘V4962’ |
SOURCE: Etter et al., 2015.
for the SGD and UEP groups. It is important as well to acknowledge the coding errors that occurred in the course of the claims processing and are part of these data and could not be detected or eliminated in the data extraction process.
Despite these limitations, however, the Medicare DME files are a valuable resource in the absence of universal data developed specifically to study the prescription and utilization of assistive devices. These data represent a good resource for determining the use of these devices among older adults and individuals with disabilities.
REFERENCES
ASHA (American Speech-Language-Hearing Association). n.d. Medicare coverage policy on speech-generating devices. http://www.asha.org/practice/reimbursement/medicare/sgd_policy (accessed March 3, 2017).
CMS (Centers for Medicare & Medicaid Services). 2010. CMS 2010 basic stand alone (BSA) DME line items public use file (PUF) data dictionary and codebook. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/BSAPUFS/Downloads/2010_DME_DataDictionary.pdf (accessed January 24, 2017).
CMS. 2016. Medicare referring provider DMEPOS data CY2014. https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/Medicare-ProviderCharge-Data/DME2014.html (accessed March 6, 2017).
CMS. n.d. Berenson-Eggers type of service (BETOS) codes. https://www.cms.gov/ResearchStatistics-Data-and-Systems/Statistics-Trends-and-Reports/MedicareFeeforSvcPartsAB/downloads/betosdesccodes.pdf (accessed January 23, 2017).
Etter, K., M. Borgia, and L. Resnik. 2015. Prescription and repair rates of prosthetic limbs in the VA healthcare system: Implications for national prosthetic parity. Disability and Rehabilitation: Assistive Technology 10(6):493-500.
ResDAC (Research Data Assistance Center). n.d.-a. BETOS table. https://www.resdac.org/sites/resdac.umn.edu/files/BETOS%20Table.txt (accessed March 6, 2017).
ResDAC. n.d.-b. Durable medical equipment RIF. https://www.resdac.org/cms-data/files/dmerif/data-documentation (accessed January 23, 2017).
ResDAC. n.d.-c. Health care common procedure coding system. https://www.resdac.org/cms-data/variables/Line-HCFA-Common-Procedure-Coding-System (accessed January 23, 2017).
ResDAC. n.d.-d. Master beneficiary summary file. https://www.resdac.org/cms-data/files/mbsf/data-documentation (accessed January 23, 2017).
