pictorial chart (PDF) illustrates the impact of coding.
It is very rare for a payor to develop its own fee schedule. The Medicare fee schedule is the basis for almost every payor. And it is rare to find a payor that pays at the full Medicare fee schedule; it is usually some discount off of Medicare. If 100 percent of the fee schedule prevents access, it is unreasonable to think that 20 percent less will have a better result. Without getting into the complexity of the formula Medicare uses to develop the fee schedule for each new HCPCS code, I will just say that when you combine dissimilar technologies and use the median price of those items to determine the payment amount, the reimbursement will be too low for the more complex items, and potentially it will be too high for the least-featured items.
What is harder for the average person to see is the change in reimbursement that resulted from years of legislation mandating reductions or freezes in the CPI-Update factors used to adjust the Medicare fee schedule each year. Between 1999 and 2014, the cumulative impact reduced the Medicare fee schedule by more than 20 percent.
Policy change that results in cuts in reimbursement is the most insidious. During my research, I identified seven items commonly provided with ultralightweight manual wheelchairs where policy and coding changes reduced or eliminated payment. The total impact for all items was a 25-percent reduction in reimbursement (see chart 1, below).
Chart 1: Impact of Policy and Coding Decisions on Reimbursement
|Example: K0005 Ultralight Wheelchair & Related Accessories|
|Initial HCPCS Code||Description / Definition||Fee Schedule Date||Fee Schedule Amount||Current HCPCS Code||Status||2014 Fee Schedule||Impact-based on last available schedule|
|K0005||Ultralightweight Adult Wheelchair||K0005||Valid Code||$2,021.71||
|K0062||Handrim with 8-10 oblique projections each||2003||$61.01||E0967||Billable replacement only||$ –||
|K0055||Seat depths, 15, 17, 18 for high strenght lightweight and ultralightweight manual wheelchairs||2003||$95.10||code deleted||Coding guidelines changed: All manual wheelchairs include all seat widths, depths and seat-to-floor heights||$ –||
|K0054||Seat widths 10, 11, 12, 15, 17, 20 for high strength lightweight and ultra lightweight manual wheelchairs||2003||$104.64||code deleted||Coding guidelines changed: All manual wheelchairs include all seat widths, depths and seat-to-floor heights||$ –||
|K0056||Seat height less than 17 or equeal to or greater than 21 for lightweight or ultralightweight manual wheelchairs||2003||$95.10||code deleted||Coding guidelines changed: All manual wheelchairs include all seat widths, depths and seat-to-floor heights||$ –||
|K0035||Heel loop with ankle strap, each||2003||$25.90||E0951||Valid Code: Descriptor changed to state with or without ankle strap; new fee schedule developed||$20.76||
|K0030||Solid insert||$95.15||E0992||Not separately billable||$ –||
|E0192||Pressure Equalizing Cushion||2004||$387.01||E2603||Coding changes in 2004: Fee schedule developed using gap-filling methodology; valid Code||$165.77||
|Impact||25.18% reduction in reimbursement|
The full picture isn’t complete, though, until you consider how product selection has changed. Unfortunately, even many clinicians are resigned to the fact that their patients cannot have the technology that they need. These changes that have happened little by little have slowly but definitely changed what consumers are provided. Most important of all is that few consumers are aware that they may have received something different, something that could improve their function only a few years ago. So while their needs are not totally met and the technology they receive may not allow them to do all the things they need and desire to do, they do get something. And the something they get is most likely in the same HCPCS code as the technology they truly need, but the fee schedule amount does not allow access to it. The loss in access is invisible to payors if the technologies are classified in the same HCPCS code.
My goal for the article in Topics of Geriatric Rehabilitation was to document years of change that have led to where we are today. My goal for this article is to encourage everyone to work alongside consumers and clinicians to fight for improved access. I believe understanding the facts is the first step. Then we must shine a light on access problems that exist and acknowledge that changes in access have been insidious. It will require all-stakeholder involvement to obtain the change that is needed to ensure that we can return to improving people’s lives through innovation and provision of CRT.