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Coding:

Watch Out For Wheelchair Downcodes With New HCPCS

Published on Thu Sep 02, 2004

CMS, wheelchair industry offer competing power wheelchair code proposals.

Are you ready for a whole new set of power wheelchair HCPCS codes to hit next summer?

Whether you will face seven, 18 or even more new codes will depend on how much the Centers for Medicare & Medicaid Services takes the industry's input into account when generating the new wheelchair coding system.

CMS' proposal: 18 new power wheelchair HCPCS E codes to replace K0010, K0011, K0012 and K0014. The three base groups of adult power wheelchairs would be Standard (which would have six subgroups with nine codes), Heavy Duty (three subgroups with five codes) and Bariatric (two subgroups with three codes), plus a code for "not otherwise specified."

The industry's proposal: seven new E codes - power wheelchairs that are: Non-modular; General Purpose Modular; Positioning Modular; Multi-function Positioning Modular; Active Performance Modular; and Heavyweight Capacity; plus a "not otherwise classified" code.

CMS is undertaking the coding overhaul as part of its Operation Wheeler Dealer crackdown on power wheelchair fraud and abuse. The industry's proposal, which has been in the works for years, was submitted by the National Coalition for Assistive and Rehab Technology (NCART).

CMS and the industry have approached their coding proposals very differently, NCART exedutive director Sharon Hildebrandt tells Eli. The industry bases its proposal on existing wheelchair technology and patients' clinical indicators, while CMS bases its codes - generated by the statistical analysis durable medical equipment regional carrier (SADMERC) - on claims processing, she says.

"Coding is more than claims processing," Hildebrandt maintains. New wheelchair codes should both consider patient needs and lend themselves to straightforward coverage policies - neither of which the CMS proposal does, she argues.

But there are many similarities between the coding proposals, notes Matthew Burke of Burke Medical Equipment Inc. in Chicopee, MA. It bodes well for the industry that CMS seems to have drawn heavily on the pre-existing NCART proposal in formulating its coding system, says Burke, chair of the American Association for Homecare's Re/hab and Assistive Technology advisory council.

Suppliers hope for a compromise between the NCART and CMS proposals. Peggy Walker, billing and reimbursement advisor for Waterloo, IA-based rehab network U.S. Rehab, favors the NCART proposal because it focuses on functionality. "That's the way it should be," Walker says.

But because CMS is unlikely to abandon its coding system, the best suppliers can hope for is a "merger" between the NCART and CMS methodologies, Walker figures.

"We prefer our codes," Hildebrandt agrees. But NCART will be pushing for CMS to collaborate with it and the industry at large to come to a "common agreement" on the final codes.

The coding proposals' highly technical nature may keep suppliers from commenting on them, experts fear. And lack of input from suppliers could pave the way for CMS to disregard many of the industry's problems with the agency's proposal.

But suppliers should be happy that CMS is so actively soliciting their input on the matter, points out Rita Hostak, VP for government relations for Longmont, CO-based Sunrise Medical. "CMS' willingness to listen to stakeholders needs to be acknowledged," urges Hostak, who serves as NCART President.

Lots of Codes Could Mean Lots of Downcodes

Downcoding of wheelchair claims is chief among suppliers' worries about CMS' coding proposal. The more wheelchair codes are available, the more the DMERCs are going to be able to reduce claims into lower-paying categories, Burke predicts. With 18 or more codes on the horizon, "we're all worried about downcoding possibilities," Walker laments.

CMS and NCART differ on the number of proposed codes mainly because the industry wants basic category codes with add-ons for items like seat width or a heavy duty upgrade, Hostak explains. CMS instead wants an entirely separate code for those configurations.

In addition to downcoding prospects, "the CMS approach has the potential of being cumbersome to use and could take time to adapt to," Hostak worries.

Other concerns about CMS' codes include:

  • Basic Equipment Package. In generating its proposed codes, the SADMERC looked at a year's worth of power wheelchair data and concluded that suppliers billed some add-on codes with virtually every wheelchair. So CMS proposes to bundle those accessories into a "basic equipment package." That package "is required to be on every chair on initial issue and will be included in the pricing," CMS says in its proposal (Wheelchairs: Basic Equipment Package Basics, for BEP components).

    But there is varying technology for these elements. "A huge range of equipment fits into that generic description," Burke protests. "It's not a one-size-fits-all kind of thing" and suppliers risk not being reimbursed adequately for the components required.

    Hostak expects the BEP concept to be one of the coding provisions suppliers protest the most.

  • Reimbursement. The big question is what allowables Medicare will set for the new codes, Walker notes. Suppliers are very concerned, but setting the fee schedule amount is usually the last step when implementing new codes, Burke says.

     Without knowing how Medicare will reimburse for these codes, it's difficult to gauge their impact on the industry, protests Erik Sokol with the Power Mobility Coalition.

  • Coverage. Likewise, the coverage policies CMS implements will greatly influence how the codes affect suppliers and beneficiaries. But CMS has yet to reveal its new policies on coverage.

    Without the reimbursement levels and coverage criteria, the wheelchair codes "are like a one-legged stool," Sokol criticizes. CMS has said its interagency wheelchair group aims to issue a draft policy of the coverage guidance by Oct. 15 (see Eli's HCW, Vol. XIII, No. 22, p. 171).

  • Weight. CMS' proposal focuses significantly on weight for classifying wheelchairs into codes - but patient weight is only one determining factor, the industry counters. "I wish it were that easy," Burke says.

    "The weight descriptor is not useful," Walker agrees. Many other factors determine what type of wheelchair is medically necessary, she contends.

  • Other payors. CMS must realize Medicaid programs and many other payors will adopt whatever codes it settles on. But its proposed codes are uniquely tailored to the Medicare population and won't serve Medicaid or other beneficiaries well, Hildebrandt warns.

    For example, the basic equipment package won't apply to many non-Medicare patients, she argues. And these codes are for adult wheelchairs only, leaving pediatric categories entirely unaddressed, Burke adds.

  • Rehab definition. CMS' codes draw "a very bright line" between rehab and basic power wheelchairs, Hildebrandt says. NCART will push for an "interim step in there" - an intermediate code between a basic and rehab chair.

    The intermediate rehab products "are often recommended for clients that may require alternate control drives, some seating and positioning needs, or maybe one powered seating system, such as power recline," Hostak explains. "But, the client does not need a combination of tilt and recline, powered elevating legrests, etc."

    At press time CMS was conducting a meeting in Baltimore to review the coding proposals and take comments on them. About a month after the Sept. 1 meeting, CMS will post a summary of the event, a CMS official said in the Aug. 25 home health Open Door Forum. The proposals and the forthcoming summary will be at www.cms.hhs.gov/medicare/hcpcs/default.asp?. 

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