2006: A Year of Reimbursement Changes

Legal Grind

Mobility providers have seen big changes in the regulatory and business environment since 2003. Providers have weathered payment reductions imposed by the Medicare Modernization Act (MMA) and the heightened scrutiny resulting from operation "Wheeler Dealer." Suppliers have demonstrated their capacity to adapt time and again. Yet, many of the policy changes resulting from the MMA and Wheeler Dealer will not be fully implemented until next year and beyond.

This may make 2006 a year of extraordinary challenges, as mobility providers make changes in their business practices to comply with the new policies.

As a result of Wheeler Dealer, mobility providers now have a new NCD for mobility assistive equipment, new codes for power wheelchairs, and a regulation that completely revamps medical-necessity documentation. CMS will implement new fee schedules for the codes Jan. 1, 2006. These changes affect all mobility providers. We discussed some of these issues earlier this year, when they were still under development. Although at press time questions remain about their implementation, it is wise to consider them as you plan for next year.

In a regulation released on August 24, 2005, CMS revised the way that power-operated vehicles (aka scooters) and power wheelchairs are prescribed and furnished. The new rule requires that a treating physician or practitioner conduct a "face-to-face" evaluation of the beneficiary before prescribing a power wheelchair or scooter. The face-to-face requirement was mandated by the MMA as a condition for coverage for power wheelchairs.

The rule contains a specific requirement that the treating physician or practitioner document the need for the power mobility device in the patient's record. Before the supplier can bill Medicare, he/she must have a written prescription from the treating physician or practitioner signed and dated within 30 days from the face-to-face evaluation. Importantly, CMS will no longer require a CMN to document medical necessity for the equipment. Instead, the supplier must have clinical documentation from the treating practitioner or physician that demonstrates the beneficiary's medical necessity for the equipment. CMS will compensate the physician for the additional documentation and for the face-to-face evaluation.

Providers have an opportunity to comment on the rule and the documentation burdens it creates, but the comment period will not delay the effective date of the rule.

On Sept. 14, CMS issued an "Announcement of Refinements" to the new power mobility codes unveiled last February and scheduled to become active on Jan. 1, 2006. This announcement was accompanied by a new set of power mobility codes for both power wheelchairs and POVs.

In part, the CMS announcement said, "Based on information gathered during the development of the local coverage determination and based on feedback from the greater mobility community regarding current testing experiences, we have identified the need to make refinements to the HCPCS codes, performance standards and testing requirements for these devices that will be implemented on Jan. 1, 2006. CMS has concluded that the current classification/testing standards published in February must be revised in order to create a sufficient methodology for identifying and differentiating among the different types of equipment … It is CMS' belief that the changes made to the coding sets will provide physicians and other practitioners with a wide range of choices that will allow beneficiaries to be placed in the most appropriate chair." Providers have an opportunity to comment until Oct. 31, 2005.

Even though there is a number of issues that require further clarification, it is clear that, at a minimum, providers must begin to address how they will work with their physician and other referral sources to make sure new documentation requirements are satisfied.

Mobility providers will need to make operational changes as well to implement the new HCPCS codes for power wheelchairs. Given the new codes announced in September, manufacturers now have until Nov. 15, 2005, to submit their code verification requests to the SADMERC. After that, CMS will issue new fee schedules for the codes. Providers will need to update their systems to include the new codes and fee schedule amounts.

Over the next several months, providers are likely to see a lot more information from CMS on every one of these issues. Each of them has the potential to affect your bottom line directly or indirectly. You will need to remain alert to the changes so that you can prepare your organization to respond to the challenges they represent.


This article originally appeared in the October 2005 issue of Mobility Management.

Rolling Dynamics, Rolling Resistance &  Optimizing Wheeled Prosthetics