2014 CRT Funding

While the Current Landscape Resembles Rocks & Hard Places, Separate Benefit Category Bills Bring Hope

Separate Benefit Category BillsYou don’t have to look far to find funding challenges on the complex rehab technology (CRT) landscape — even with many CRT wheelchair codes excluded from competitive bidding.

As 2013 draws to a close, the industry is bracing for a couple of potentially new funding-related regulations to adapt to in 2014.

(A disclaimer: This content was accurate as the issue went to press. Look for funding and policy updates in eMobility newsletter additions.)

New Face-to-Face Exam Enforcement

Asked which reimbursement issues he’s hearing most about, Jim Stephenson, CMC, rehab reimbursement & coding manager for Invacare Corp., cites the new Medicare requirement for face-to-face encounters. Many types of DME, from hospital beds to standard manual wheelchairs, will require “detailed written orders for face-to-face encounters conducted by the physician, physician’s assistant (PA), nurse practitioner (NP) or clinical nurse specialist (CNS) for certain DME items,” according to MLN Matters article MM8304.

The Centers for Medicare & Medicaid Services (CMS), citing “continued concerns that some providers and suppliers may need additional time to establish operational protocols necessary,” says it will begin “actively enforcing and will expect full compliance with the DME face-to-face requirements beginning by a date that will be announced in calendar year 2014.”

Stephenson’s concern: “The effective date is going to remain July 1, 2013. It’s not being enforced right now; that’s basically what the delay is, they’re not enforcing it. Whenever they decide to fl ip the switch and say OK, we’re enforcing it now, and RAC and CERT and all the other auditing contractors start grabbing claims, they’re going to be looking back till July 1, 2013, for face-to-face information.”

That revelation was announced, Stephenson reports, during a September Webinar that was presented by NHIC Corp., the DME MAC for Jurisdiction A.

“So between July 1 and the day of this Webinar, people just assumed that the effective date was not going to be in place until [2014],” Stephenson points out. “[An NHIC representative] got on this Webinar and explained that the effective date is written in legislation — [Medicare] can’t change the effective date without an act of Congress, so it’s just delaying enforcement at this point.”

The potential problem: “If they’re leaving the [effective] date as July 1, 2013, then whenever enforcement kicks in, people could technically be on the hook for anything that’s happened since [July 1]. So there could be some pretty significant challenges coming down the pike providing that the enforcement and effective date don’t become one at some point.”

Since many providers aren’t yet collecting face-to-face documentation — a fact acknowledged by CMS and cited as the reason for the implementation delay till 2014 — Stephenson predicts “with auditors and so forth, that’s going to be low-hanging fruit for them. That’s something that’s going to be easy to recoup, probably every single claim that gets filed.”

Assuming that the July 1, 2013, effective date by law cannot be changed, Stephenson says the hope is that CMS will instruct its auditing contractors not to look for or demand DME face-to-face documentation from claims filed prior to the to-be-announced implementation date. “It’s really too early to tell right now,” he says.

A couple of other DME face-to-face notes to keep in mind: Stephenson says power mobility devices (PMD) covered under the existing PMD face-to-face regulation will not be impacted by the DME version. In general, the DME face-to-face regulation is less involved. “There’s not anything that says the visit has to be for the sole purpose of assessing somebody for a standard wheelchair, like it is with power wheelchairs,” he explains. “[The visit] just has to have been done within the six months previous to when the order is written.”

Plus: “If a physician’s assistant or a nurse specialist is the one that’s writing [the prescription], for the new face-to-face requirement the physician still has to sign off on it.” With the PMD face-to-face requirement, “a nurse practitioner or PA or nurse specialist, as long as they’re working within the confines of their licensure in the state where they’re working, can sign exclusively without having a physician sign off on it.”

New Capped-Rental Proposed Rule: Now Waiting for a Verdict

As we went to press, the industry was also waiting for CMS’s next move regarding the capped-rental proposed rule that could impact dozens of CRT HCPCS codes, from the E1161 adult manual tilt-in-space wheelchair, to the E1235 pediatric adjustable wheelchair with rigid frame, to the E2325 sip-and-puff interface.

The comment period for the proposed rule closed on Aug. 30. Since then, says Rita Hostak, VP of government relations for Sunrise Medical, “There is not a lot of additional information other than that our comments are in. A lot of key organizations submitted very thoughtful, very detailed comments. We all shared key concerns and key points to be sure everybody was covering as much of the important pieces as possible.”

And now, the industry waits. “Historically, CMS has held the position that they cannot discuss regulation that’s currently under development or comment period,” Hostak says.

At stake for the CRT community: Whether those dozens of complex rehab codes, currently paid for up front, will be forced into the cappedrental payment category.

CRT stakeholders contend that the capped-rental payment model — in which Medicare pays for a piece of equipment over time via 13 monthly payments — is inappropriate for CRT items. Typically, capped-rental items are ready-to-use, out-of-the-box products needed by Medicare beneficiaries for a short amount of time. Medicare therefore saves money by paying a monthly rental fee rather than buying the item outright, and when the item is no longer needed, it is returned to the equipment supplier, who typically rents it to another beneficiary. CMS has said that on average, beneficiaries need capped-rental products for only eight months.

In contrast, CRT experts say, complex rehab products are used by people with severe and permanent disabilities. People using a head control proximity switch or a manual wheelchair power-assist system — both items are on the capped-rental proposed list — will need that equipment for much longer than eight months.

“That contradicts [CMS’s] whole theory of savings, of saying the average person uses it for eight months and then turns it back in,” Hostak says.

As for the theory that CMS perhaps wants to rent CRT equipment because the agency expects its beneficiaries to pass away before the 13-month rental period ends, Hostak points out that’s not the most likely scenario.

“Even if you say, ‘But what about patients with ALS?’ — they’re not using manual chairs, most likely. Most likely, they’re going right into power. And complex rehab power has already been exempt [from the capped-rental rule]. So even if you look at that population of people who have a prognosis of a shorter lifespan, typically they’re not getting [proposed capped-rental] equipment at the end-of-life sort of stage.”

So why did CMS include so many complex rehab items in the cappedrental proposed rule?

“I think what we have to assume is that the people who were writing the proposed rule said, ‘We’re going to look at equipment that is expensive and may or may not have high utilization,’” Hostak says.

Given CMS’s goal of implementing the new capped-rental rule at the start of 2014 — barring an implementation delay, which is still possible — Hostak adds that the industry should get replies to its comments in the near future.

“It’s at the point now that we probably won’t hear anything out of CMS until the very end of October or the first of November, somewhere in there,” she says. “There’s obviously a notice period, and they’re looking at this being implemented by January of 2014.”

As the industry waits, Hostak suggests stakeholders keep talking to legislators. If nothing else, the proposed capped-rental changes provide a perfect transition to discuss a separate benefit category for CRT.

“The only thing for us to do is to make sure that we’re keeping members of Congress aware of what’s going on,” Hostak says. “CMS has said a couple of times that [it’s] addressed CRT differently in the quality standards and classified it differently: ‘You told us the K0005 was CRT so we said it is; you said the E1161 is CRT, so we said yes, you’re right; [the same with] Group 3 power chairs and so forth. So we really don’t understand why you feel you need a separate benefit category.’”

The capped-rental proposed rule, Hostak notes, is a concrete example of how different CRT is from DME, and why it needs to be set apart.

“This is a perfect opportunity,” she says, “because almost anybody can look at an item that’s individually configured for one person that’s going to be used by a person with a permanent disability — and then think, ‘Renting that would be good why?’ That’s an easy one for somebody to look at and say, ‘I can see why you wouldn’t want to rent that.’”

Good News for Adjustable Cushions

While favorable funding topics are admittedly difficult to find just now, there is good news in the form of adjustable seat cushions.

“The bright spot is that adjustable cushions didn’t get included in the bidding,” says Dave McCausland, senior VP of planning & government affairs for The ROHO Group. “It’s not a permanent exclusion necessarily like complex rehab items, but it’s excluded from round 2 [of competitive bidding] and it’s excluded from the rebid of round 1.”

The four impacted and now excluded codes are E2622 (skin protection wheelchair seat cushion, adjustable, width less than 22", any depth); E2623 (skin protection wheelchair seat cushion, adjustable, width 22" or greater, any depth); E2624 (skin protection and positioning wheelchair seat cushion, adjustable, width less than 22", any depth); and E2625 (skin protection and positioning wheelchair seat cushion, adjustable, width 22" or greater, any depth).

“Obviously, clinicians want to get the best they can for their patients, and now at least they’re not going to have a limitation based on what the winning bid rate is for those particular categories,” McCausland says. “For the end users, they can continue having access to products that really do have proven clinical benefits to try to protect their skin from breakdown, which obviously can become catastrophic.” Bid winners, McCausland adds, can provide the adjustable cushions at full reimbursement rates, while providers who didn’t win bids can also continue to provide adjustable cushions.

“The access at least won’t be as limited,” says Tricia Garven, PT, ATP, clinical applications manager for The ROHO Group. “People shouldn’t balk at reproviding that adjustable cushion, because [funding levels] aren’t going to change.”

The competitive bidding news isn’t as good for another seating category: the general-use back. Thanks to Medicare’s willingness to pay for a general-use back for the beneficiary who qualifies for a manual or power chair (models with captain’s seating excluded), the niche has seen tremendous product development in recent years. That’s been good news for consumers needing more support than a sling-style back could offer.

Unfortunately, McCausland says, things are changing thanks once again to competitive bidding. “We’re going to see a paradigm shift there. Here’s the paradigm from the standpoint of reimbursement: They were being reimbursed for general-use backs roughly between $290 and $340 for the allowables. Now, under round 2 of competitive bidding, if you take the winning bid rates for the general-use backs and determine the average rate, it’s $160.63.”

Complicating matters, McCausland adds, is that the general-use back “is a very broadly defined code. Basically, if you can get it to attach to a wheelchair by any mechanism and it covers the back, it can get coded there. There are some really good products in the general-use category, and I’m hoping there will be more new products developed that are good in that category. What I’m afraid you’re going to start seeing is a migration toward lessercost, lesser-quality products because dealers are going to have to address the fact that their revenue on each one of these just got cut in half.”

“The pretty picture for general-use backs,” Garven says, “is the qualifications are you just have to have a wheelchair that’s not captain’s-style seating. If you qualify for the wheelchair, you can get a general-use back, so that is beautiful. The bad news on most of the competitively bid chairs is who is going to qualify for general-use and not positioning [backs]. That’s where the funding issues happen.

“The nice thing about the general-use category is it’s not diagnosis specific. So if you have somebody who does need increased stability or who has needs for a better-than-upholstery solution, but they don’t have a diagnosis that qualifies, that’s where the general-use back code fits in. That general-use category of offerings is very broad, from the very simple to those that are very similar to versions of positioning backs.”

McCausland adds, “Sadly, the other codes for the positioning backs have some fairly tight verbiage with regards to the requirements to fit into those codes. If a product doesn’t fit into one of those unique buckets, the only other code that the government’s got right now is general-use.”

Instead of grouping very simple and much more complex backs into the same general-use category (and with the same reimbursement), would the industry — including end users — benefit from having more specific codes to delineate different functions and features of different backs?

“Absolutely,” McCausland says. “Look at the seating codes. You’ve got [cushion] codes that are general-use, skin [protection], positioning, combination skin-and-positioning, and then you’ve got adjustable and non-adjustable. If they did that same thing in the back category, you’d have 12 codes. That’s not a huge number, but you’d be able to address their unique features.”

Separate Benefit Category: Making Progress

So many CRT funding challenges, from competitive bidding to cappedrental changes, segue naturally into the larger conversation of a separate benefit category for CRT. It’s an effort that has been building for years, and 2013 marked the first time the industry has had separate benefit category bills active in both the U.S. House and the U.S. Senate.

“We’re happy with the progress we’re making,” says NCART Executive Director Don Clayback. (At press time, H.R. 942 had 77 co-sponsors, and S. 948 had five.)

“As more people sign on,” Clayback adds, “particularly as we start working with the staff on the key committees within Congress — the Ways & Means committee on the House side and the Finance committee on the Senate side — we’ll be explaining in more detail what we’re trying to accomplish, what the problems are, and why we think this is the solution. And then we’ll look to educate them and get their input, and see if there’s modifications that they may need. Then we’ll have discussions around that.”

Another item to anticipate: A score from the Congressional Budget Office (CBO) to estimate the cost of establishing the separate benefit.

“Once the bill moves farther down the road and starts getting more attention, that’s when we’ll get in the to-do line of the CBO, and scoring would be part of the process before it would get ultimately attached to something and pass,” Clayback explains.

As far as next steps, Clayback says, “We’ll be competing as always to make sure our issue doesn’t get lost in the fray. It’s a small bill, and I don’t think a controversial bill, so we can work towards getting attached to a larger piece of legislation. That’s the good news. The bad news is we are a small bill, so to make sure we get enough awareness and get some of our champions in Congress to make this a priority is really part of the strategy.”

Those working on the bills are watching for upcoming possibilities to attach to other bills.

“You’ve got the physician fee schedule reduction that’s scheduled. Certainly Congress is going to pass something to either delay that for a year or potentially eliminate it,” Clayback says. “So that’s a Medicare issue that’s going to be addressed, and that might be an opportunity for us to get attached. And then the more controversial thing you’ve got is healthcare reform. That’s a very partisan issue, you’ve got a lot of discussion going on around that.”

The separate benefit category bills’ supporters point out that they have bipartisan support, and that the industry commissioned its own independent study to estimate the cost of the bills.

“The bottom line with the scoring,” Clayback says, “is that we understand the cost of any bill is important, and we would love it if we could have a CBO score today. Knowing how Congress works and that a CBO score is down the road, we went out and spent a significant amount to have a D.C. firm give an estimate using a CBO model. And that’s where we got our $56 million [estimated cost] from. So we can share with [Congressional] members: We’d love a CBO score, and if you can get it for us, great. If not, here’s what we’ve done to give some indication of what the cost would be. We think it’s a small population [of consumers], it’s a small group of specialized equipment, and so they’ve come up with this $56 million. That doesn’t include any offsets, such as people getting the right equipment the first time, or the right evaluation so they don’t develop pressure sores and require hospitalization. We’d like you to sign on based on the merits of the legislation, and we understand the CBO score is certainly a threshold that we need to work through somewhere down the road. If the CBO comes up with some estimate that’s much higher than that, we’re going to have some work to do to help educate the CBO and see what modifications we need to make to be sure this is something that Congress can get behind and pass.”

CRT’s current funding issues — such as the newer proposed cappedrental rule — give stakeholders another opportunity to point to the separate benefit campaign as a chance for real reform, rather than continuing a “Band-Aid” response when CRT gets caught up in a CMS funding net.

“It’s another example of why we need a benefit,” Clayback says of the proposed capped-rental changes. “To their credit, if you go back to round 2 of competitive bidding, CMS was going to include complex rehab manual wheelchairs. They did include them in their first announcement of the billing codes. CRT stakeholders came together, we met with CMS and to their credit, they listened to us and pulled those out.

“I’m not naïve, but we’ve got some precedent where we’ve brought these issues up, and we’ve been successful in getting CRT treated the way it needed to be treated. This, I think, will be another example. I also think it helps bolster our position with Congress on why we need this [separate benefit category]. People say, ‘Why do you need this?’ Here’s another example of where we’re getting included in these things, when really these products shouldn’t be, and it’s taking a significant amount of time to get this resolved. We have to involve Congress, and a lot of people get engaged, and it’s something that in our minds is fairly straightforward and obvious.”

It has and continues to be a long haul, but Clayback contends it’s also one capable of making real changes to the system.

“Legislation is a very lengthy and time-consuming process, but in the mean time, there have been some good things that have come as a result of this initiative. The removal of complex rehab manual chairs from round 2 was a direct result in my mind of our effort around CRT advocacy. We’re making inroads with some Medicaid programs, and we’ve got discussions going on with them: in some states it might be legislation, in other states it might be working with the Medicaid department to provide a better delineation between CRT and DME. So there are those little steps that we’re making towards improvement. The challenge is that as many steps as we make forward, new issues pop up that we need to battle. That’s just the reality of the healthcare arena.”

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

In Support of Upper-Extremity Positioning