Navigating between the Scylla of an industry clamoring for broader reimbursement of power wheelchairs and the Charybdis requiring a cap to these costs, the Centers for Medicare & Medicaid Services (CMS; Baltimore) has released new draft criteria and codes that it hopes will skirt both extremes while providing “proper payment.“

The proposed new criteria from Medicare would put greater emphasis on “clinical guidance“ for evaluating the needs of those seeking the powered devices, it said, as well as “exactly what type of device is needed.“ This approach would replace the previous standard that defined the appropriate reimbursed patient as “non-ambulatory or bed- or chair-confined,“ it said.

This broader analysis would begin, the agency said, with whether the beneficiary “has a mobility limitation that prevents him or her from performing one or more mobility-related activities of daily living in the home.“ This evaluation would also consist of “whether or not an assistive device — whether a simple cane or a sophisticated power wheelchair or anything in between — would improve the beneficiary's ability to function within the home.“

The revised criteria will also consider other impairments, such as visual or mental, that impact the patient's ability to use the mobility equipment, according to CMS.

The proposed revisions in standards appears to be a large win for the makers of power wheelchairs and scooters, following roll-out of “Operation Wheeler Dealer,“ launched by CMS in late 2003.

Wheeler Dealer specifically targeted ballooning increases in reimbursements for the devices, with Tom Scully, then-administrator of CMS, reporting a 450% increase in reimbursements during the previous four years (Medical Device Daily, Sept. 11, 2003). Agency officials at the time said that payments for the power devices had soared from $10 million in 1994 to $1.2 billion in 2003 (MDD, April 2, 2004).

The much more specific target of the program involved soaring reimbursements generated out of the state of Texas in which the equipment was never provided or the claims were alleged as fraudulent, CMS said.

But providing heavy pushback to what the government termed its “clean-up campaign“ was the power mobility industry and Restore Access to Mobility Partnership (RAMP; Washington), a coalition representing a group of manufacturers in the sector. RAMP charged that a strict interpretation of traditional CMS guidelines had resulted in blocking access to the mobility equipment by the many thousands of patients who legitimately needed them.

RAMP subsequently developed what it termed a “task force“ of occupational and physical therapists to push for guidelines using clinically based criteria as well as input from clinicians in the field (MDD, Aug. 24, 2004).

The new guidelines appear to meet those criteria, but on Friday a RAMP spokesperson told MDD the organization was still evaluating the proposed new criteria and had “questions“ concerning their specific implementation.

The process for developing the new criteria was outlined in CMS's Modern Mobility Initiative announced last April. And the need for more specific guidelines may have been bolstered by a California court decision which challenged the government's right to reject reimbursement claims that come with physician documentation (MDD, July 12, 2004).

CMS has set Feb. 24, 1 p.m.-4 p.m. EST, as the date for an Open Door Forum concerning the proposed national coverage decision (NCD) and to clarify issues on which CMS is seeking comment.

Mark McClellan, MD, PhD, CMS administrator, said in a statement that issuance of the NCD moves the agency “closer to our goals of supporting appropriate prescribing, making accurate payment and providing clear guidance to physicians and suppliers about power mobility devices. This will take us a long way toward bringing this important benefit into the 21st century. It also makes it clear that Medicare recognizes the importance of clinically-based coverage decisions.“

The statement credited Sean Tunis, MD, chief medical officer for CMS, with spearheading the agency's move to the more functional assessment, adding that the proposed criteria “were developed with the intention of providing clear and consistent guidance to Medicare contractors and to clinicians to ensure that beneficiaries receive the type of mobility device that will provide clinical benefits.“

CMS said it would publish the final NCD in March and provide guidance on how to use and document the new criteria.

CMS also is establishing new billing codes for power wheelchairs and scooters to assure that payments are made “appropriately“ for these devices. Medicare said it would expand the number of codes used for billing from five to 49 “to better reflect the range of power mobility products now available on the market.“ The new codes will improve payment and “facilitate getting the right products to patients,“ CMS said.

Herb Kuhn, director of the CMS Center for Medicare Management, said, “The technology, range of products and market for power wheelchairs have changed substantially since the . . . codes for power wheelchairs were last revised in 1993. Currently, Medicare uses only one code, K0011, to pay for most power wheelchairs. Having more codes will permit us to more accurately reflect the different kinds of mobility products our beneficiaries are using.“

CMS said the new codes will incorporate “testing standards in several areas, such as weight capacity, fatigue testing, speed and range testing.“ The codes will go into effect Jan. 1, 2006.

CMS said it would publish “in the near future“ a regulation implementing provisions affecting power mobility equipment, including removal of the requirement that only certain specialists can prescribe a power scooter. In addition, the regulation will require a “face-to-face meeting“ between the prescribing clinician and the beneficiary before a scooter or wheelchair can be ordered.

The agency said it also is developing “quality and consumer standards“ for all suppliers of durable medical equipment, prosthetics, orthotics and supplies, as well as standards for specific product lines, including power mobility devices.“

These standards, CMS said, “will implement strong quality controls for suppliers who play a key role in ensuring that a particular piece of equipment is appropriate for the individual beneficiary, and that it will be usable in the home setting,“ The agency plans to finalize these “in the fall“ of this year. It will implement these standards “through an accreditation process conducted by one or more accreditation bodies to be designated at a later time.“

The proposed NCD will be posted on the CMS web site, with comments accepted until March 7. A description of the new Medicare billing codes for wheelchairs will be posted at www.cms.hhs.gov/suppliers/dmepos.

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