Reimbursement Series

Access to Complex Rehabilitation Technology

Can We Still Improve People's Lives?

Access to Complex Rehabilitation TechnologyI have been working in the durable medical equipment (DME) and complex rehabilitation technology (CRT) industry since 1982. For the first half of my career, there was a steady climb in innovation. Technology developed in basements and garages seemed to almost seamlessly transition to manufacturing facilities and supplier networks, making it available to the people who needed them. CRT in many ways leveled the playing field for people with disabilities, at home, work, school and in their communities.

Technology kept pace with advances in rights for people with disabilities and allowed people to take advantage of opportunities to work, go to school and live full and satisfying lives.

Unfortunately, anyone who has been involved in providing CRT in the last 10 years has witnessed significant changes in access. It didn’t happen all at once; it has been insidious.

A few years ago, I started trying to keep track of the various changes that have impacted access to CRT. Some of the changes were significant, like the dramatic changes in coding, coverage and payment for power mobility devices in 2006. Some appeared to be minor, like the elimination of the ability to bill for non-standard handrims at initial issue of a manual wheelchair. But it is the cumulative effect of years of change that has truly altered access.

Starting with a Clean Slate

A desire to expose and explain the cumulative effect is what motivated me to write “Medicare and Complex Rehabilitation Technology: A 20-Year Review, The Impact of Medicare Legislation and Regulation on Complex Rehabilitation Technology Access and Innovation,” which was published in the January-March 2015 edition of Topics of Geriatric Rehabilitation.

As I researched the myriad changes to ensure I captured as many as I could and that the facts regarding each were accurate, I was stunned. When you consider the convoluted documentation requirements and face-to-face requirements, and add them to the coding, coverage, and payment changes, it is a wonder any CRT is provided.

Something must change, and it must happen quickly. We will not be able to undo 20 years of policies, rules and legislation overnight. However, I do believe the separate benefit category initiative, being led by the National Coalition for Assistive and Rehab Technology with support from a stakeholder steering committee, is the industry’s best opportunity to start with a clean slate. Starting with a clean slate is our best hope of improving access, and improving the lives of people with disabilities.

To know what must change, we must understand the root cause of our current reimbursement pain. It is important to acknowledge that very few policy makers or legislators know the history. Without an understanding of the cumulative effect of changes, and an understanding of why the current level of funding is in inadequate, it is difficult for decision makers to believe that another reduction, small or large, has the potential to block access to CRT and close more CRT businesses around the country.

To develop a good understanding of why we are where we are, I routinely use the analogy of a three-legged stool to describe reimbursement: coding, coverage and payment. If any one of these three elements of funding is inadequate or inappropriate, access will be reduced or denied.

The Three Legs of the Stool

Coding is one of the most complicated components of funding. The Health Insurance Portability and Accountability Act of 1996 mandated the use of the Healthcare Common Procedure Coding System (HCPCS) for all payors. This was not fully implemented until 2003, when the use of local codes (codes that were unique to them and not part of a national code set) by non-Medicare payers was eliminated. Non-Medicare payors routinely created local codes for items such as pediatric or bariatric equipment, custom equipment, or for items that they covered, but Medicare did not.

Industry groups worked alongside Medicaid staffs to develop requests for new HCPCS codes and submitted applications requesting new codes for items that had previously been assigned to local codes. The results from these efforts are a big part of the pain we feel today. In many situations, CMS chose to classify technology into existing codes and to change code descriptors to state, “any type” resulting in very complex technology being assigned to the same code as a standard item of DME. The pictorial chart (PDF) illustrates the impact of coding.

It is very rare for a payor to develop its own fee schedule. The Medicare fee schedule is the basis for almost every payor. And it is rare to find a payor that pays at the full Medicare fee schedule; it is usually some discount off of Medicare. If 100 percent of the fee schedule prevents access, it is unreasonable to think that 20 percent less will have a better result. Without getting into the complexity of the formula Medicare uses to develop the fee schedule for each new HCPCS code, I will just say that when you combine dissimilar technologies and use the median price of those items to determine the payment amount, the reimbursement will be too low for the more complex items, and potentially it will be too high for the least-featured items.

What is harder for the average person to see is the change in reimbursement that resulted from years of legislation mandating reductions or freezes in the CPI-Update factors used to adjust the Medicare fee schedule each year. Between 1999 and 2014, the cumulative impact reduced the Medicare fee schedule by more than 20 percent.

Policy change that results in cuts in reimbursement is the most insidious. During my research, I identified seven items commonly provided with ultralightweight manual wheelchairs where policy and coding changes reduced or eliminated payment. The total impact for all items was a 25-percent reduction in reimbursement (see chart 1, below).

Chart 1: Impact of Policy and Coding Decisions on Reimbursement

Example: K0005 Ultralight Wheelchair & Related Accessories
Initial HCPCS Code Description / Definition Fee Schedule Date Fee Schedule Amount Current HCPCS Code Status 2014 Fee Schedule Impact-based on last available schedule
K0005 Ultralightweight Adult Wheelchair     K0005 Valid Code $2,021.71


K0062 Handrim with 8-10 oblique projections each 2003 $61.01 E0967 Billable replacement only $ -


K0055 Seat depths, 15, 17, 18 for high strenght lightweight and ultralightweight manual wheelchairs 2003 $95.10 code deleted Coding guidelines changed: All manual wheelchairs include all seat widths, depths and seat-to-floor heights $ -


K0054 Seat widths 10, 11, 12, 15, 17, 20 for high strength lightweight and ultra lightweight manual wheelchairs 2003 $104.64 code deleted Coding guidelines changed: All manual wheelchairs include all seat widths, depths and seat-to-floor heights $ -


K0056 Seat height less than 17 or equeal to or greater than 21 for lightweight or ultralightweight manual wheelchairs 2003 $95.10 code deleted Coding guidelines changed: All manual wheelchairs include all seat widths, depths and seat-to-floor heights $ -


K0035 Heel loop with ankle strap, each 2003 $25.90 E0951 Valid Code: Descriptor changed to state with or without ankle strap; new fee schedule developed $20.76


K0030 Solid insert   $95.15 E0992 Not separately billable $ -


E0192 Pressure Equalizing Cushion 2004 $387.01 E2603 Coding changes in 2004: Fee schedule developed using gap-filling methodology; valid Code $165.77


          Total $2,208.24


          Impact 25.18% reduction in reimbursement

The full picture isn’t complete, though, until you consider how product selection has changed. Unfortunately, even many clinicians are resigned to the fact that their patients cannot have the technology that they need. These changes that have happened little by little have slowly but definitely changed what consumers are provided. Most important of all is that few consumers are aware that they may have received something different, something that could improve their function only a few years ago. So while their needs are not totally met and the technology they receive may not allow them to do all the things they need and desire to do, they do get something. And the something they get is most likely in the same HCPCS code as the technology they truly need, but the fee schedule amount does not allow access to it. The loss in access is invisible to payors if the technologies are classified in the same HCPCS code.

My goal for the article in Topics of Geriatric Rehabilitation was to document years of change that have led to where we are today. My goal for this article is to encourage everyone to work alongside consumers and clinicians to fight for improved access. I believe understanding the facts is the first step. Then we must shine a light on access problems that exist and acknowledge that changes in access have been insidious. It will require all-stakeholder involvement to obtain the change that is needed to ensure that we can return to improving people’s lives through innovation and provision of CRT.

This article originally appeared in the March 2015 Mobility Management issue of Mobility Management.

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