Wheelchairs & Funding

Funding Watch: When Will Ultralightweight Chairs Be Recoded?

When Will Ultralightweight Chairs Be Recoded?Revamping HCPCS codes for durable medical equipment and complex rehab technology can be long, drawn-out processes.

The Centers for Medicare & Medicaid Services (CMS) put new codes for wheelchair seat cushions into eff ect in 2004. After that, CMS tackled the power mobility segment: New K (i.e., “temporary”) codes have been used since 2006.

As CMS was laboriously expanding K0010, K0011, K0012 and K0014 into nearly 60 new power chair codes, we kept hearing that manual chair recoding would be next. They’re on the horizon. They’re slated to be done.

But in subsequent years, that chatter has all but stopped. So: Is recoding manual wheelchairs, including ultralightweight models, still on CMS’s radar?

New Codes in Our Future?

“The answer to that is that CMS has not indicated any desire or willingness to modify manual wheelchair HCPCS codes at all,” says Rita Hostak, VP of government affairs for Sunrise Medical.

“Dr. [Doran] Edwards, when he was the medical director for the SADMERC [Statistical Analysis Durable Medical Equipment Regional Carrier], spent a tremendous amount of time and effort meeting with the industry, doing research, understanding the differences in the technology and the clinical applications, and had developed a very detailed and comprehensive proposal,” Hostak recalls. “He had taken what the NCART coding group had put together and — much like he did with the power wheelchair [recoding] — took it, analyzed utilization from a Medicare perspective and had worked up his own proposal. I think he got to a point where he was able to submit that to CMS and got basically no traction.”

Then CMS changed contractors, and the newly named Pricing, Data Analysis & Coding contractor (PDAC) took over for SADMERC. “Dr. Edwards was gone,” Hostak says, adding, “Absolutely nothing has happened since then” regarding new codes for manual chairs.

So is recoding for manual chairs no longer on CMS’s radar?

“It’s not in line anymore to be looked at,” Hostak says. “And actually I think that CMS’s perspective around coding has changed, has morphed. It’s really quite different than it would have been even five or six years ago.

“Now CMS is trending more toward bigger buckets with a broader range: an array of technology within a given code. At least a decade ago or so, prior to HIPAA, there was definitely a recognition of technological differences, clinical application differences, that sort of thing. Today, ‘It looks like a wheelchair, it feels like a wheelchair, it’s a wheelchair: Why do you need more than one code?’ is more of the mentality than what we would have witnessed a decade or so ago.”

Long-Lived “Temporary” Codes

By definition, K codes are temporary codes, stand-ins until permanent E codes are announced. The K codes for manual chairs have been standing in for a long time, indeed.

“The ultimate loser in this scenario,” Hostak says, “is consumers, for a couple of reasons.

“One is that the codes and the corresponding reimbursement for most of the codes — the adult manual wheelchair codes, except for tilt — were created in 1993 based on technology that’s now 20 years old. So you take that code that had very specific technology that it was designed for, and now you’ve just kind of shoved products into those codes whether they really were similar or not.”

Hostak points out that even as newer, innovative products are forced into old codes, CMS historically hasn’t raised reimbursement rates. “But I think more importantly, because none of those codes were really well defined, what you find is while the code was created with specific products in mind, it lacks the kind of specificity and clarification as to how you have to qualify for that code. So much-less-featured items now fit into that same code.”

Due to multiple years of fee schedule freezes, Hostak has noticed providers having “to move toward the less-featured products in order to be able to provide them under the current reimbursement. Consumers that are newly injured or have newly acquired mobility problems may not know what they’re missing. They may not be able to say, ‘Wow, 10 years ago I could have gotten something much better than this for the reimbursement rate.’

“But consumers that have had the technology for five years, 10 years, 20 years, are coming back to get a replacement chair and are shocked to see what Medicare and in many cases Medicaid is going to allow them to have access to from a reimbursement perspective. So you have the access problem for the consumers.”

Future Innovations Endangered

While consumers are already suffering as CMS continues to force new products into old codes without raising allowables to compensate for new technology, Hostak says wheelchair users will also suffer in another, less tangible way.

“It’s hard for a manufacturer to justify spending the R&D dollars to invest in innovation while knowing that their ability to get a HCPCS code and proper coverage and payment is minimal at best,” she points out. “So it’s not only causing a decline in what’s available in terms of features and functions for consumers, but it’s also created a huge barrier towards innovation. In a market of people with disabilities, innovation is really important.

“Keeping product design and product function and features in line with allowing them to be more active, more integrated into the community, returning to work, returning to school, having as normal a life as possible absolutely should be what everybody’s focused on. At the end of the day, if you can’t get paid for it, you can’t do it. Consumers are absolutely the ones that are being the most significantly impacted by it.”

This article originally appeared in the June 2013 issue of Mobility Management.

About the Author

Laurie Watanabe is the editor of Mobility Management. She can be reached at lwatanabe@1105media.com.

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