11-02-2006
My grandfather taught me the only thing constant in life is change, and that change isn’t bad, it just sometimes can be a bit awkward trying to get there. Finally, the power wheelchair codes are providing some change in an industry desperate for it, but it has been a bit awkward. Over the past couple of years CMS, the MAC’s and the SADMERC have had open door forums, created a new National Coverage Determination, reviewed applications of tested product, involved a technical expert panel, classified and coded the product, and created an LCD policy to help administer this new era of funding (allowables due out any day). The process has been nothing short of a roller coaster ride. The ride, in which I was barely tall enough to enjoy to begin with, started with 18 codes, to 49 codes, to 65 codes, and ending with 64 codes. My stomach can’t take much more of this amusement.
To be honest, I’m simply pleased the government woke up and recognized that the K0011 code, the one size fits all power wheelchair code, was like putting a shoe on that didn’t fit and the next day finding a throbbing blister as a result. A blister the federal government had to address sparking “operation wheeler” dealer, and ultimately, the new code set. So will these new codes and policy solve the problems of the past? Let’s take a look of what I like and what I don’t coming out of Washington:
What I like:
1. I like the algorithm approach to determine the right product for the individual. The NCD created this practical line of attack to systematically eliminate product until the right choice is clear. In addition, the NCD recognized that bed and chair confined was out of date and that assisting with MRADL’s was the way to go.
2. I like the face-to-face documentation requirement. This is long overdue in a world where drop shipping was the norm and not the exception. Hopefully, end-user’s won’t turn on the TV at two in the morning, order their wheelchair, and have it on their front porch by lunch time the next day.
3. I like the RESNA certification requirements in the LCD. Finally, if a person has their hands all over you conducting a seating and positioning assessment, they will be certified to do so. I think having the certification by April 2008 is a bit ambitious, but hey, if you build it, they will come.
4. I think it was important that down-coding to group 1 was eliminated from the LCD. Either it is medically necessary or not, don’t play around with beneficiary’s diagnosis by providing the least amount CMS can get away with. We’re better than that.
5. Thank goodness “independently” was inserted into the LCD, Group 3, stand and pivot language. I firmly believe this was the intent all along but too many believed this provision had the potential of being abused. I still think it can be tweaked, for instance, to include the double amputee who would not currently fall under the definition of neuromuscular or myopathy.
6. I like that the codes requires performance based testing in order to classify product. I know there were issues in regard to the testing, and we can work on that, but the theory is sound. The higher the diagnosis, the more quality, steadfast chair is required. Nice.
7. Last, I like that the SADMERC recognized a high-end category (Group 4), even though that more than likely there will not be an allowable for those codes under Medicare. What it does allow, however; is to provide Medicaid and private insurance to follow codes as required under HIPAA. States and private insurance will still have their own allowables and policies but the codes will be mandatory.
What I Dislike:
1. I have concerns with the documentation requirements concerning doctors and their progress notes. I understand the intent but I’m afraid the $23 G code allowable is just not attractive enough for a doctor to take the time to sit down and justify assistive technology they know nothing about. The triage approach is the bright spot here, but the doctors are going to need time to understand, but I’m concerned when that day comes they will still not be interested.
2. I’m not in favor of putting seating options in group 2. If a beneficiary has a diagnosis that is going to require seating and positioning then they should be in a group three and have the performance enjoyed at that level. It is my understanding the final codes may eliminate seating options in group 2 which I will be in favor of at that time.
3. The fee schedule determination is offensive. To include online pricing, when the companies that trade over the internet do not meet MMA accreditation standards, is an exercise in futility. Further, the wholesale pricing had no definition. What was wholesale for one manufacturer may not have been so for another. I hope the fee schedule ends up reasonable, otherwise; what’s the point?
Our efforts are paying off and the changes are still a work in progress, but all in all, I like where we are going as an industry, and our working relationship with the government is a plus. We need to continue to be involved with the decision making and continue to have our representative’s email addresses’ close by and handy, because competitive bidding and manual wheelchair codes are on deck and in the hole.