A Critical Time for PMD Providers

Legal Grind

Earlier this year, we looked ahead to the changes facing mobility providers. The outgrowth of the so-called "Wheeler Dealer" initiative included a new national coverage policy, a new local coverage policy, new documentation requirements (including a "face-to-face" evaluation of the beneficiary by the physician), revised coding for power mobility, and, along with the new codes, reimbursement changes.

Questions remain about the documentation necessary to support power wheelchair claims.

In August, the product classification lists for the new codes were announced. Almost immediately, there was concern that some of the products were not properly classified based on the information that manufacturers submitted to the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC). As of the date of this writing, the SADMERC is engaged in reviewing the product classification and making adjustments. These changes are important, because improper classification of the products in a code can affect the reimbursement for the code.

In mid August, the Centers for Medicare & Medicaid Services (CMS) also released a spreadsheet with pricing data for each of the new codes. Because many of the products in the codes were misclassified, there is the possibility that the misclassified products resulted in incorrect pricing for the codes.

More importantly, the CMS spreadsheet identified three sources of pricing for the new codes — the median manufacturer's suggested retail price (MSRP), median wholesale, and median Internet pricing. CMS requested public comments on these pricing sources, but did not reference how it intends to use the pricing in developing new fee schedules. In particular, CMS requested public comments on what additional pricing sources for power wheelchairs CMS should consider.

On Aug. 15, the DME Program Safeguard Contractors (PSCs) released the final local coverage determination (LCD) for power mobility devices. Although the industry requested an additional comment period on the LCD to address policy issues in light of the new codes, the PSCs nonetheless issued a final policy. A troubling aspect of the LCD is the reliance on least costly alternative pricing. Also, because the product classification must be corrected, it is unclear how the least costly alternative methodology applies to any specific product.

[Editor's Note: On Sept. 20, the DME PSCs released a revised LCD for power mobility devices, as much of the industry was in Atlanta for Medtrade. At press time for this issue, the industry was still assessing what impact the revisions would have, and how the revisions would be interpreted by claims reviewers. Among the changes: Elimination of "automatic downcoding" of beneficiaries from Group 2 or 3 power chairs to Group 1 chairs, if they did not meet certain criteria; and the addition of the word "independently" when referring to a beneficiary's ability to perform a stand-and-pivot type of transfer. Accompanying the revised LCD was an announcement that implementation for the LCD had been delayed from Oct. 1 to Nov. 15, 2006.]

Finally, earlier this year, CMS regulations requiring the face-to-face evaluation became effective, but questions remain about the scope and timing of the documentation necessary to support power wheelchair claims. Recently, the DME PSCs issued long-awaited additional guidance on documentation, but — again — there continue to be important concerns about what constitutes appropriate documentation, even in light of this guidance.

By the time you read this, the Nov. 15 LCD deadline will be very close, making an effective or "seamless" implementation of these changes challenging. As a first step, everyone should read and understand the final LCD and the most recent documentation guidelines. You should also begin to incorporate into your business the processes that reflect these new guidelines. At the same time, you need to remain vigilant for announcements of new developments. Last-minute adjustments to some of these initiatives seem inevitable.

This article originally appeared in the October 2006 issue of Mobility Management.

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