Feeling the Pressure

Say what you will about the ongoing Centers for Medicare & Medicaid Services (CMS) saga regarding power mobility coverage criteria, new codes and new allowables, but there is this good news: The size of the power wheelchair and scooter market, relative to home medical equipment in general, is large enough that it gets a lot of attention.

Compare that uproar to the much smaller seating & positioning niche, composed of cushions, power seating functions and positioning hardware such as headrests, ankle huggers, abductors, adductors and laterals. The coverage criteria, new codes and accompanying allowables have caused big headaches here, too, and there's definite concern that some beneficiaries, particularly on the high end of rehab, are not getting the equipment they truly need.

But because the prices of the items in this niche are lower, this portion of the market has been somewhat overshadowed not only by bigger-buck wheelchairs and scooters, but even by concerns over cuts to other DME items and services, such as portable oxygen.

The Current Landscape

So where does that leave seating & positioning? What does its funding landscape look like right now?

"I don't think I would say things are okay," says Invacare Corp.'s Mark Sullivan. "If you take just the basic (wheelchair ) cushions and backs -- not the powered stuff -- we've gone through a couple of cuts. So the industry's taken some pretty good hits on that over the last couple of years. It's stable right now, but really, (CMS) has cut back too far. It gets very, very difficult to afford some of the higher-end cushions."

And just because end-users haven't been flooding their legislators with protests doesn't mean consumers haven't already been hurt, Sullivan says.

"It's always hard to prove access problems, because consumers tend to not complain," he explains. "But we have heard that some providers will not provide certain high-end cushions" because they literally can't afford to.

Sullivan adds that some other positioning equipment "hot spots" besides high-end cushions also remain. "We've got the issue with power elevating legrests -- what (CMS) used to allow (i.e., the reimbursement rate) for each is now (a) per pair (rate). So it's become very difficult for people to be able to afford to provide power elevating legrests. That's been a significant problem."

And ELRs aren't the only area of concern, Sullivan says. "Certainly, (there are other trouble spots) in the power positioning area, such as seat elevation (and) standing -- which CMS continues to deny as not medically necessary. Let's take seat elevation -- it's something almost every consumer would benefit from in the home in doing MRADLs (mobility-related activities of daily living) in terms of grooming, transferring, eating, doing dishes. Seat elevation helps with all of that, and it's used in the home -- that's where you need it. It doesn't do you all that much good outdoors. So it's kind of ironic that Medicare refuses to pay for that."

Providers are having similar difficulties in medically justifying standing equipment, Sullivan says. "Standing is more limited in terms of the number of people that can benefit from it. Obviously, if you've got some contractures, you can't really stand. But for some people, in terms of access, (standing) provides a great function in the home."

Sullivan says funding for tilt and recline functions is "pretty much okay," but he adds, "Again, we went through some cuts about two years ago, which hurt."

Overall, Sullivan compares the seating & positioning funding landscape to a famous metaphor. "It's the old saying, 'Death by a thousand cuts.' Each of these things, by itself, is not a death blow. But combined -- and on top of that some of the cash-flow problems people are having as some of the states and managed-care organizations convert over to the new coding structures, the accreditation and competitive bidding (programs) that are coming… these things are cumulative."

The ROHO Group's Dave McCausland points to CMS' own Part B Extract Summary System (BESS) Carrier Data File -- in simple terms, how much CMS actually spent -- as proof that Medicare funding of seat cushions has sharply declined the last few years.

"What this shows is a substantial drop in expenditures and utilization of seat cushions since the implementation of the new policy," McCausland says. "With the cutting of the allowables and the tightening up of the coverage criteria, (the 2005 expenditures, which are the most recently available numbers) are almost half of what they were in 2003… the fee schedules were cut so dramatically. You're talking about cuts of 20, 30, 40 percent. You compound that with utilization requirements, and it's a pretty stark market for seating right now."

Quoting the BESS Data File, McCausland points to CMS expenditures on seat cushions for 2003, the last year before CMS' policy change. McCausland says the BESS numbers show CMS spent more than $55.5 million solely on seat cushions in 2003.

In 2005, CMS lumped together all its expenditures for seat cushions AND equipment newly labeled with the miscellaneous K0108 code. After adding seat cushion and K0108 expenditures together, CMS said it still spent just $38.3 million total in 2005. "That's a cliff," McCausland says of the expenditure drop-off. The number is even more dramatic when you consider that the sharply reduced $38.3 million figure for 2005 includes K0108 products -- defined as miscellaneous wheelchair parts and accessories -- that aren't even cushions.

"The two problems that still are causing this particular market segment to be depressed," McCausland says, "are the fact that the fee schedules are so low and that the methodology that requires you to match specific ICD-9s (codes) is really not dynamic enough to reflect the varieties of conditions that actually exist out in the marketplace."

McCausland related a recent conversation with a supplier who was attempting to justify a skin-protection cushion for a client with a litany of medical conditions. "He went through all the problems this person had, but unfortunately, the (ICD-9) diagnosis wasn't there. We could qualify the person for a positioning cushion, but not for skin (protection)." The supplier's incredulous comment: "So I have to wait for the person to literally (experience skin) breakdown before I can protect him?"

The Headrest Example

While headrests and head positioning systems are just one seating & positioning funding "hot spot," they were singled out by several industry members as examples of just what's wrong with the current funding picture.

Sunrise Medical's Tom Whelan explains the problem this way: "In the HCPCS code set, there's only one code -- E0955 -- available for all headrests. A headrest, by definition, can be as inexpensive and simple as a piece of foam glued to a piece of wood with any type of covering, mounted to another piece of wood, mounted to a wheelchair. That's a headrest. So is this example -- we make a headrest that has four individual positioning pads that go around the head that connect to a two-bar linkage so that when you move your head to rotate from left to right, you'd be held up and supported, but you'd have a natural rotation at the cervical spine."

Whelan says both of these headrests would be reimbursed at $212, according to current Medicare allowables.

"If you look at our marketplace and the sensitivity we have to fraud and abuse, when you submit $212 for a piece of plywood bolted to a chair, (the funding system is) getting abused," Whelan points out. And he adds that manufacturers, providers and ultimately end-users are hurt when the same payor is only willing to reimburse $212 "for all the time, effort and everything it takes to put in a rotational headrest, plus make it… So the code system is not supposed to, legally, deny access and facilitate fraud and abuse. But that's what happens when you have this kind of code set."

"There are two codes used for headrests -- E1028 and E0955, with E1028 being a hardware code," says Gabriel Romero, Stealth Products. "I've got products that have multiple hardware (pieces) on it. We have head-positioning and head-support -- two totally different types of items. The industry knows it, but SADMERC didn't know it. We have multiple items that all do a special thing -- there are pads with gel for pressure breakdown, there are positioning pads that will actually align somebody… it's a system, but (CMS) gives it a general code. They'll say, 'What do you mean you're paying $900 for this headrest? Give 'em that $200 headrest.'"

One Code Fits Few

The common concern that seating & mobility specialists voiced is that the current code set is not doing a detailed enough job of differentiating between basic and more complex products.

One such example, says Varilite's Kevin Coleman, is high-end wheelchair cushions. "Although CMS created adjustable and non-adjustable categories of cushions, the Skin Protection and Skin Protection & Positioning classifications imply that adjustable and non-adjustable cushions perform equally. This has created a risk that clients may be downcoded to a cushion that is not the best solution for them."

"The current reimbursement scheme," Coleman states, "encourages downcoding."

Romero says, "We work with SADMERC on the coding and up-and-coming codes. What I found out is we don't have enough codes. You hate saying that, because I'm not a dealer -- I'm not the one going to the insurance companies and trying to figure it out. But really, we don't (have enough codes) -- because they're specialty items. And in our industry, with seating & positioning items, they're not coded right. So you may have a pad that has a special type of hardware, but (the allowables) aren't broken down right."

Romero says he also met with competitive manufacturers who make the same sorts of products that Stealth does -- and there was a consensus that the existing codes just weren't able to adequately meet dealer or end-user needs. "We have dealers who are saying, 'I can't break this down and get paid back for this because the allowables are so low.'"

Exceptions to the Rule

In some cases, positioning equipment for more involved clients -- i.e., equipment with greater customization or complexity -- has been reclassified under the miscellaneous K0108 code (wheelchair component or accessory, not otherwise specified). In those cases, the equipment could qualify for greater reimbursement rates (assuming the required justification and documentation are provided) than it would have received had it not been given the miscellaneous code.

The problem: Is the miscellaneous code being evenly and fairly applied to all the equipment that deserves it?

Whelan says a mandate from CMS required the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) to stop reclassifying already-coded products under the miscellaneous code. Whelan added that though SADMERC staff agreed that not all headrests are created equal or perform identically, headrests nonetheless continue to be all contained under the E0955 code.

"I don't blame Dr. (Doran) Edwards and the SADMERC staff, because that's not where the problem lies," Whelan says. The result, he adds, is "an inequitable landscape," because products that were reclassified under the miscellaneous code remain under the K0108 code, but no additional products can be considered for K0108 reclassification because of that CMS mandate.

Accentuating the Positive

Whelan says the SADMERC "has been working with us to develop code sets that are more robust." The hope is that a greater number and a greater variety of codes will be able to more accurately describe the differences among complex products. Since CMS has already nixed the idea of continuing to reassign the miscellaneous codes to products, adding additional codes seems to be the only way to go.

"Hopefully, the solution is that sometime in the next year and a half, we'll get a new code set," Whelan says.

Of course, even the prospect of a new code set does not automatically give this story a happy ending, as Whelan points out: "A year and a half of people getting denied access to medical technology is a problem."

"It's not all doom and gloom in terms of the industry," Sullivan says. "People are going to figure out how to provide this stuff to the consumers. They're going to have to figure out a way to run their businesses differently. Quality is going to be important just because you can't afford to go out and keep fixing things. You've got to turn down the number of offerings. You just have to have a much leaner operation."

"If there is any silver lining to what has happened to wheelchair expenditures since the implementation of the new policy," says McCausland, "it is that I hope that what has happened will keep this being a category that (CMS) competitvely bids. Because there's no money left. There's no blood left."

In Support of Upper-Extremity Positioning