Home Health & Hospice Week

But final wheelchair NCD lets in-home restriction remain.

There's good news and bad news in the final national coverage determination CMS rolled out last week for mobility assistive equipment.

The good news: The Centers for Medicare & Medicaid Services is replacing the "bed or chair-confined" standard with function-based clinical criteria that looks at whether beneficiaries have personal mobility deficits that sufficiently impair their participation in mobility-related activities of daily living in the home setting. These activities include everyday things like toileting, eating, dressing and bathing.

"This coverage policy ensures that a beneficiary's functional status and individual circumstances are considered so that the most appropriate technology for each beneficiary's personal needs is covered," says CMS Acting Chief Medical Officer Barry Straube. "It is also consistent with the documentation of the functional needs of the patient that should be in medical records for our beneficiaries."

CMS' Interagency Wheelchair Working Group recommended the functional ambulation standard after considering peer-reviewed scientific data, expert opinion and public comments. The new standard takes effect immediately.

"We applaud CMS for accepting the recommendations of the IWWG," Eric Sokol, director of the Washington-based Power Mobility Coalition, tells Eli. "PMC members have long believed that the existing [certificate of medical necessity] already established a functional ambulation test, but we applaud CMS for codifying it in this new coverage determination."

Documentation Issues Remain Unsettled

The bad news: The NCD addresses only claims going forward, so pending claims will still be subject to the restrictive bed or chair-confined standard.

Furthermore, though CMS acknowledges the need to address medical necessity documentation issues, it defers resolution of those matters to a future initiative. PMC is urging the agency to revise the current physician-certified CMN to reflect the new NCD criteria and remain the Medicare document of record for claims processing.

"CMS is hoping to apply more exacting clinical standards and an algorithmic formula to determine eligibility and proper wheelchair placement," says PMC attorney Stephen Azia. "Such a formula should be reflected in a revised CMN to ensure that eligible beneficiaries get appropriate equipment and that suppliers will have more than a reasonable expectation that a physician-certified CMN establishes eligibility."

Leaders of the Atlanta-based Clinician Task Force, comprised of seating and wheelchair practitioners, also have a number of complaints about the NCD. They include its failure to define clearly "mobility related activities of daily living" and failure to include mobility itself as a MRADL. That omission severely limits the NCD's functionality, according to the CTF.

But perhaps the biggest disappointment to clinicians was CMS' decision to preserve the in-home restriction for mobility equipment. The in-home restriction "conflicts with standard clinical practice, clinical evidence and public policy," says Barbara Crane of the CTF.

The PMC says it will continue to work with advocacy groups to get legislation introduced in Congress to lift the in-home restriction.

Editor's Note: CMS' final decision memo on the NCD for mobility equipment is at www.cms.hhs.gov/mcd/viewdecisionmemo.asp?id=143.