Medicare Compliance & Reimbursement

Implementation on codes, LCD delayed until Nov. 15.

Medicare will still pay for a Group 2 power mobility device (PMD) when appropriate, say the feds in a recent "clarification" from the Centers for Medicare & Medicaid Services (CMS).

A Fact Sheet issued by CMS on Sept. 20 clarifies the point, saying that many have "misinterpreted" a local coverage determination (LCD) that was set to go into effect Oct. 1. The LCD was widely held to mean that Medicare would deny many claims for Group 2 (general use) power wheelchairs.

"Unless they require special seating, people needing a power wheelchair will only receive coverage for what many wheelchair users call a 'junk wheelchair,' a device that has no ability to ride over even the smallest bump and has extremely limited battery power," protested the Medicare Rights Center, an advocacy organization with offices in New York City and Washington, DC, in a statement issued earlier this month, before the clarification.

The LCD does not call for such a blanket down-coding of Group 2 (general use) to Group 1 (light weight) power wheelchairs, assures CMS Office of External Affairs.

"We commend [CMS] for recently issuing a Fact Sheet/Press Release and revision of its Local Coverage Determination in an effort to ensure that Medicare beneficiaries receive the most appropriate power mobility devices to meet their medical needs," said Mike Pfister, president of the New Braunfels, TX-based firm The Scooter Store, in a statement released Sept. 26.

As result of that change and other, relatively minor tweaks, the effective date for the new codes and LCD will be changed to claims with dates of service on or after Nov. 15, 2006. The feds will amend the LCD issued by the Durable Medical Equipment (DME) Medicare Administrative Contractors, making the interpretation official and binding.

"The LCD will be modified to incorporate this and other changes so that there will be no confusion surrounding the basic intent of Medicare's policy," according to CMS.

The clarified LCD will be issued by the durable medical equipment Program Safeguard Contractor Medical Directors, says CMS, adding that the clarified LCD has been adopted by the DME Medicare Administrative Contractors.

In addition, CMS says it will issue the long-awaited fee schedule corresponding to the new HCPCS codes "in the near future."

The clarified policy is available at the following Web sites: www.trustsolutionsllc.com/DRAFT_LCD_Status.asp, www.tricenturion.com, and www.edssafeguardservices.eds-gov.com/providers/dme/lcd.asp.

Many PMD Suppliers Are Leery Of CMS' Assurances

Restore Access to Mobility Partnership (RAMP), a coalition based in Bethesda, MD, is calling on the CMS for more policy revisions and pricing information relating to the newly revised LCD.

The group applauded CMS for working with stakeholders to clarify some issues in the revised LCD. However, the coalition of power mobility manufacturers and suppliers reiterated industry concerns that additional policy revisions and pricing information are still needed.

While RAMP said it appreciates the change, it is requesting additional assurances from CMS that downcoding will not occur. "At this point, stakeholders are merely seeking a letter or some kind of other written confirmation that this will be the policy so that it won't ever be an issue in the future when claims are under appeal or under review," the organization said.

RAMP also said CMS should eliminate the stand-and-pivot criterion used to determine whether a Medicare beneficiary qualifies for a Group 3 power wheelchair. Only patients who are incapable of an "independent transfer" qualify for a Group 3 chair, but some stakeholders are concerned that a literal interpretation of "independent" could include people who face a severe struggle to transfer themselves.

This requirement should be replaced with clinical criteria that will provide access to the proper medical equipment for patients requiring complex rehabilitation, RAMP said.