Medicare Compliance & Reimbursement

Change would dump bed- or chair-confined standard in favor of functional ambulation.

A ray of light may be ready to shine through the hazy fog of wheelchair coverage.

The Centers for Medicare & Medicaid Services convened Interagency Wheelchair Workgroup has issued its recommendations for changes to Medicare's power wheelchair coverage guidance, and they include dumping the old "bed- or chair-confined" standard in favor of a new, functionally based ambulation standard.

"Functional ambulation means the ability to walk, with or without the aid of appropriate assistive devices (such as prostheses, orthoses, canes or walkers), safely and sufficiently to carry out mobility-related activities of daily living," the workgroup notes in its report.

Instead of decreeing a patient bed- or chair-confined, physicians could work through a series of nine clinically oriented questions to assess a beneficiary's functional ambulation and determine the appropriate-level device to restore a patient's mobility-related activities of daily living, the workgroup recommends.

"This is very positive," says Seth Johnson, director of government affairs for Exeter, PA-based Pride Mobility Products Corp. "We are pleased the workgroup came down there" on the issue.

The change is "a victory," says Erik Sokol of the Power Mobility Coalition. The bed- or chair-confined terminology has been misinterpreted and clear functional guidance will be a significant improvement, Sokol tells MLR.

National Coverage Determination Initiated

But it may be a long road until the workgroup recommendation makes it into practice. Originally, CMS said it would issue the clinical guidance by Dec. 31. But now instead of just implementing the guidance, CMS is taking it through the regimented National Coverage Determination process.

Good news: Under the NCD process, there will be plenty of opportunity for public comment before the recommendations become mandated. "After the IWWG drafted its recommendations, CMS concluded it should review the recommendations and re-examine its own policies using the NCD process, a transparent, science based policy making process that assures opportunity for public input," CMS says in a release.

Bad news: The wait for a final coverage determination may be until next September. "It is a rather lengthy process," Johnson laments.

Solution: Sokol and Johnson are calling for CMS to issue immediate guidance to durable medical equipment regional carriers, making clear that functional ambulation should be used to determine coverage rather than bed- or chair-confined.

"Beneficiaries are being denied access" to mobility equipment they should qualify for, Johnson insists. Certain DMERCs continue to employ an overly strict interpretation of the bed- or chair-confined rules to improperly deny claims, Sokol adds.

Under NCD rules, CMS first takes public comment on the guidelines - the deadline for those comments is Jan. 14. CMS then will issue draft guidelines by March, according to the NCD timeline.

Positive comments about the recommendations are already coming in. "This document will go a long way towards setting a reasonable standard for the provision of [power operated vehicles] to consumers," Jimmie Arceneaux, occupational therapist and clinical manager for Metro Preferred Home Care, says in public comments on the guidelines posted Dec. 21.

Editor's Note: The workgroup report and NCD instructions are at www.cms.hhs.gov/mcd/viewtrackingsheet.asp?id=143.