Home Health & Hospice Week

New HCPCS codes slated for fall.

Now that the government workgroup on wheelchair clinical coverage guidance has been assembled, it's putting the pedal to the metal on getting the new criteria out.

As a result of Operation Wheeler Dealer, the federal crackdown on power wheelchair fraud in the Medicare program, the Centers for Medicare & Medicaid Services has put together an "interagency wheelchair workgroup" of clinicians and policy-makers to "produce clinical guidance for the coverage of wheelchairs, power wheelchairs, and power-operated vehicles," CMS says.

The 16-member workgroup consists of federal employees from various departments of CMS, the Department of Health and Human Services, the Veterans Administration and the Department of Education, CMS Chief Medical Officer Sean Tunis explained in a June 14 special Open Door Forum on the wheelchair clinical guidance. The members include physicians, occupational therapists, physical therapists and a chiropractor.

In government terms, CMS plans a speedy issuance of its clinical guidelines. The workgroup will gather public input on the issue until Sept. 1, then will develop a draft policy that CMS will issue by Oct. 15, Tunis revealed in the forum.

CMS will accept comments on the draft and hold another Open Door Forum about it, then hopes to issue a final policy by Dec. 31. "I am excited about the timeline," said Doug Harrison, president of The Scooter Store based in New Braunfels, TX. Harrison deemed the timeline "aggressive" in the forum.

CMS and the workgroup will do its best to stick to the timeline, although the volume of information received could influence it, Tunis said. But he made the schedule public to keep the agency "accountable," he said.

Issuing clinical guidance is just one part of CMS'ongoing wheelchair campaign, a CMS staffer said. The agency is working on changes to the "overly broad" K0011 HCPCS code for power wheelchairs and plans to solicit public input on the draft this fall. The changes would become final in July 2005, CMS plans.

Watch out: The onset of competitive bidding in 2007 is another motivator to get the wheelchair code changes in place quickly. More specific coding categories make for an easier bidding process. "That's another reason to tackle this coding problem right now," the CMS source admitted.

CMS'program integrity department is undertaking action in three wheelchair-related areas:

1. Supplier standards. CMS is overhauling its current 21 supplier standards both to make it harder for bad actors to enroll and to clarify requirements, a CMS official said in the forum. Inventory, contracting and insurance are three areas especially in need of clarification. "We want to make it as clear as possible so that people know what we expect of them," she said.

The clarification is expected by "early fall," the official noted.

2. Quality standards. The committee that will advise CMS on competitive bidding (see Eli's HCW, Vol. XIII, No. 21) also will review the new supplier quality standards required by the Medicare Modernization Act passed last December. CMS will seek public input as well, perhaps through a Web site posting or Open Door Forum, the staffer said.

3. Accreditation. MMA also requires accreditation for all Medicare suppliers.

While CMS is starting this new flurry of wheelchair-related activity, wheelchair suppliers are being hung out to dry, one supplier who attended the session in person complained.

Many power wheelchair claims have gone unpaid for months, and the result may be that suppliers have to go take wheelchairs back from customers, the supplier warned -- especially in Harris County, which is still under heightened claims review. "Customers are discriminated against as well as our businesses," he charged.

The Scooter Store's Harrison warned that the DMERCs continue to deny wheelchair claims based on the December 2003 memo from CMS that supposedly clarified wheelchair coverage. The memo was so controversial that CMS had to pull it, but DMERCs still haven't gone back to their claims processing procedures from before the memo, he said.

DMERCS are denying claims "right now, today" based on the stricter definition of bed- and chair-confined contained in that memo, Harrison claimed.