Home Health & Hospice Week

CMS unveils new criteria for power mobility equipment.

The Centers for Medicare & Medicaid Services has released new draft coverage criteria for power wheelchairs and scooters, and the proposal is getting mixed reviews from suppliers.

The good news: CMS plans to ditch the confusing and restrictive "nonambulatory" or "bed or chair confined" standard and instead consider a beneficiary's ability to ambulate safely around the home to accomplish activities of daily living.

The bad news: The national coverage determination fails to address the "in the home" restriction on such equipment. In addition, the new coding initiative released with the NCD expands the number of codes used for billing for power equipment from five to 49 - a situation that some say could create an administrative nightmare for both suppliers and CMS.

"On the whole, we're fairly pleased with the direction of this proposal," Eric Sokol of the Power Mobility Coalition tells Eli. "But if CMS makes the system too complex, what will happen when we go to competitive bidding?" The agency would have to accept bids for 49 power wheelchairs alone, he notes.

The NCD relies on clinical guidance for evaluating whether a beneficiary needs a mobility device and what kind. The analysis first considers whether the beneficiary has a limitation that prevents him from performing one or more mobility-related activities of daily living in the home.

It also considers whether an assistive device would improve the bene's ability to function at home, and whether conditions such as visual or mental impairment affect her ability to use the equipment appropriately.

CMS' Interagency Wheelchair Working Group, which includes clinicians, researchers and policy experts from various federal agencies, recommended the functional ambulation standard after examining scientific data, expert opinion and public comments.

Payment Ceilings on New Codes Yet to Come

CMS developed the new set of codes by working with the Statistical Analysis Durable Medical Equip-ment Regional Carrier and the DMERCs, and by considering comments on draft wheelchair codes released last fall (see Eli's HCW, Vol. XIII, No. 31).

Rationale: The agency insists there's a good reason for the explosion in the number of codes. Expanding available codes beyond the oft-used K0011 would help CMS "more accurately reflect the different kinds of mobility products our beneficiaries are using," according to Center for Medicare Management Director Herb Kuhn.

Not all DME experts believe the increased number of codes will present big problems for suppliers. "I don't think it will affect providers that much," predicts Peggy Walker of U.S. Rehab. "But I feel sorry for the people at SADMERC who will have to go through this coding."

However, Walker notes that the revised codes still include temporary K codes, meaning more changes are possible in the future. "So this could happen to us again," she cautions.

The new codes incorporate testing standards in several areas including weight capacity, fatigue, speed and range. CMS plans to develop payment ceilings for each of the new codes, which would take effect on Jan. 1, 2006. PMC has called on CMS to solicit supplier and manufacturer input when developing the ceilings.

Make your voice heard: "Failure to be inclusive in this process could lower reimbursement to the point of driving suppliers out of the market, especially in rural and underserved areas," Sokol warns. "Suppliers would also be forced to look beyond American manufacturers if margins were drastically cut."

As for eligibility determinations, the PMC is calling on CMS for "clear and reasonable" documentation requirements. To that end, the organization wants the current certificate of medical necessity revised to reflect the new NCD criteria and to remain the document of record when processing Medicare power mobility claims.

Meanwhile, patients' rights advocates have joined suppliers in criticizing the proposal's failure to remove the in-home restrictions. In fact, the Medicare Rights Center said it would ask the White House to review whether the proposal contradicts President Bush's New Freedom Initiative.

Mark Your Calendar for NCD Q&A

CMS plans to publish the final NCD in March and to provide guidance on how to use and document the new criteria. It also plans to hold a special Open Door Forum on Feb. 24 from 1 to 4 p.m. EST to give suppliers, physicians and beneficiaries a chance to ask questions about the proposed NCD.

Editor's Note: The proposed NCD will be posted at www.cms.hhs.gov/coverage, and comments will be accepted until March 7. The new billing code descriptions are at www.cms.hhs.gov/suppliers/dmepos. ODF information is at www.cms.hhs.gov/opendoor.