Funding Series

Comprehending Cushion Codes

Skin Protection, Positioning & Adjustability: Their Impact on Funding

• By Laurie Watanabe
• Aug 01, 2016

So much depends upon wheelchair seat cushions, particularly for clients with complex seating needs. An optimal cushion in the right seating system can give its user more comfort, safety and function in his or her wheelchair. The wrong cushion can be catastrophic.

So much therefore depends upon cushion funding, which in turn depends on a cushion’s HCPCS code. The variables for cushions commonly used by complex rehab clients are skin protection and positioning — used alone or together — plus adjustability. And it’s much more complicated than it sounds.

Cushion History, Revisited

To understand current cushion codes, it’s helpful to look at their history — how codes were written and why.

That means going back more than 10 years, when industry experts worked with Doran Edwards, M.D., medical director of Medicare’s Statistical Analysis DME Regional Carrier (SADMERC, which later became the Pricing, Data Analysis & Coding contractor [PDAC] after a contractor change), to revise cushion codes.

Rita Stanley, Sunrise Medical’s VP of government relations, was among the industry members working on the project.

“Part of what Dr. Edwards was doing was looking at the different technologies and trying to understand the different materials that are used,” Stanley said. “‘Is there a difference between foam and fluid, and do I care? When do I care, and how do I know when enough is enough?’ [Edwards] reached out to RESNA; he talked to the committee involved in developing those tests and getting those tests passed, approved and accepted as an ANSI/RESNA test, and part of the issue that we ran into in 2004 is there wasn’t enough time. It’s not an easy thing to do, creating a new test and getting it signed off by all the different people who serve on those committees and boards. He ran out of time to have RESNA create a new test that would test this concept of adjustability.”

When the new codes first came out, Stanley said, “There was just skin protection, positioning, and the combination of skin protection and positioning.” The result: Different forms of technology with varying efficacies were in the same code and therefore received the same reimbursement.

“Products that were fluid based, air-flow based — JAY products, ROHO and others — were suddenly not available because the reimbursement level for a basic skin protection cushion just wouldn’t have allowed it,” Stanley said. “The response of the stakeholders, whether consumers or clinicians or manufacturers or suppliers, was pretty extreme and immediate. So I think CMS (the Centers for Medicare & Medicaid Services) and Dr. Edwards realized, ‘We’ve got a problem and we’ve got to address it. But how do we address it? Because we don’t have time for the ANSI/RESNA test component of this.’”

Preserving Code Integrity

Skin protection wasn’t the only area that caused concern, says J. David McCausland, VP of planning & government affairs for ROHO Inc. McCausland was also part of the industry team that worked with Edwards.

“When we created the seating policy, we felt it was important that products assigned to codes met certain performance characteristics, that [they] also met certain durability characteristics, and certain safety characteristics,” McCausland said.

The seating policy includes an immersion test — originally developed by Stephen Sprigle, Ph.D., PT, McCausland noted, and also known as an “indenter” test — plus an aging test to measure a cushion’s longevity and a fire retardancy/safety test. But the tests lacked certain specifics that have proven problematic.

“The indenter test basically pushed these cylinders, which were 40 cm long to represent the ischials, down into the cushion to see if they could immerse so far,” McCausland said. “The way they were to evaluate durability is you would then age the product. Some of the cushions would be aged to a year; in other situations, the cushion was to be aged to 18 months. And then you’d run the immersion test again. The logic was Does it continue to function after 18 months of simulated use? So it’s not five years of durability, but at least you know that the product continues to provide some benefit over some period of time.

“Here’s the problem: They did not put in the policy any requirements with regards to what anybody has to do to accelerate aging on their product. There was no description, no minimum requirement, nothing about laundering, nothing about repetitive loading, and nothing about heat aging. It was really subject to interpretation, and you could have manufacturers that perhaps were a bit too lenient in what they considered to be the minimum aging before they’d run the test again.”

McCausland said the safety test also lacks practicality.

“We have a fire-retardancy test, but it’s the California [Technical Bulletin] 117 test, which is basically a cigarette test. Does it really make sense to do a test of an open flame sitting on top of a cushion, when realistically, that’s where the person would be sitting? You need to do fire tests or safety tests looking at the edge or looking at something from the bottom.”

Adjustability: Macro vs. Micro Changes

In addition to skin protection and/or positioning, current cushion codes include categories for adjustability, a concept that Stanley said has been particularly difficult to capture.

“There had been originally a concept that adjustability had two meanings,” Stanley said. “It was adjustable in that you could put air in it, you could put fluid in it, and then you could take it out or add it at a later date to adjust it. That was one way to look at it, and that might be important if you had a person that gained weight, lost weight, whatever the situation was that the clinician decided in the field, ‘This isn’t meeting their needs right now.’

“The other piece of it was critically important when it comes to skin protection. And that was Does the material have the capacity to adjust throughout the day as the person moves or shifts or changes how they’re sitting on that cushion? And that is a much more difficult part of the cushion to test.”

Though clinical experts worked to develop a test that could quantify a cushion’s ability to make “micro” adjustments throughout the user’s day, eventually the team ran out of time. The result, Stanley said, was cushion policy that limits adjustability to “macro” adjustments — the ability of a skin protection cushion to be modified after delivery to the client. Left out of the policy: a cushion’s ability to adjust on the fly in response to weight shifts that wheelchair users have when rolling down a ramp or leaning to pick something up from the ground.

McCausland’s issues with the adjustability portion of policy start with the adjustable cushion’s construction.

Examine the local coverage determination, which says, “Wheelchair cushions containing a fluid medium — air, gas, liquid or gel — that have the capability for the immersion characteristics of the cushion to be altered by an addition or removal of fluid will be considered adjustable. The adjustment may be in the manner of direct addition or removal of the fluid, e.g., adding or removing air, or indirectly by the addition or removal of packets of fluid. … Adjustable as applied here requires that the procedure is capable of being performed by the beneficiary or caregiver using the items supplied at the time of the initial issue of the device in response to the beneficiary’s need for more or less skin protection because of weight loss, gain or muscle tone changes.”

McCausland noted, “So that has several key points in it which I think need to be called out. It calls out that there has to be a fluid medium in it. That the fluid medium is specific for skin protection. That the adjustment has to be capable of being done by the beneficiary or caregiver in response to the beneficiary’s need for changes over time. The whole thought of an adjustable cushion is [the client is] going to change, so we have to make sure the cushion can change to continue to provide them the best environment. That’s right in the policy, and yet the PDAC over the last few years has started coding products to the adjustable codes that have no fluid, [just] a slab of foam.”

His point, McCausland said, was not to “bad-mouth any of these products. They might be very good, and maybe they deserve some new coding. But we bastardize the integrity of the codes if in fact we start assigning products that don’t meet the description into these codes. I know we worked very hard to make sure we had a definition that met the skin protection needs of these individuals over time. And you can’t do that with a solid piece of foam. It has to have a fluid that you can add or remove.”

How Codes Impact Funding

Stanley is concerned that the loose definition of adjustable — one that takes macro, but not micro adjustability into account — could hurt funding for cushions that do offer more complete adjustability.

Some 12 years after the industry worked with Edwards, CMS has “lost sight of the need to adjust that definition to also include the adjustable characteristic of the material that the adjustable cushion is made from,” she said. “That’s a really critical thing that’s missing, so when people start saying, ‘How do I decide? Do I need just a skin protection cushion, or do I need an adjustable skin protection cushion?’ — I would suggest that people who are most capable of making that choice do it based on their experience as wheeled mobility and seating specialists or wound care specialists who have observed how their patients respond to different technologies. It’s that evidence-based practice, it’s evidence that has been observed through years of doing it that allows those clinicians to be knowledgeable about the technology and how their particular patient presents. They know they need air or they need fluid or they need this kind of material, and that’s only likely available in an adjustable cushion code.

“It’s their understanding and knowledge and experience as therapists and clinicians that’s going to drive them to the right cushion. It’s not going to be based on policy or the definition of the code as CMS has it today.”

Manufacturers who want both macro and micro adjustability in their cushions — who “are going to genuinely develop innovative product that makes every effort to address all the elements that contribute to skin injury,” as Stanley said — will be challenged by other manufacturers who take the less expensive route of concentrating just on cushions with macro adjustability.

And there’s also the potential that CMS will take a closer look at micro-adjustable cushions and wonder whether the extra costs are justified — especially because adjustable cushions are not part of Medicare’s competitive bidding program.

“Standard skin protection cushions have been in every round of competitive bidding,” Stanley pointed out. “So as you see the reimbursement for a standard non-adjustable skin protection cushion go down further and further and you have more of a delta between the adjustable and the non adjustable, that’s going to make payors say, ‘Tell me again why I’m paying that much more for adjustable. What is it?’ And we’re missing the ability to demonstrate some of what’s really critical and what makes the differences between those categories of products so important.”

McCausland agreed that competitive bidding upended what had been an industry system of checks and balances. “For so many years, we were used to fee-for-service structures,” he said. “Even if you had 2,000 items assigned to a single code, if the dealer wanted to maintain their livelihood, they had to satisfy the caregiver, the clinicians and the end user. There’s nothing worse for a provider than ticking off one of your referral sources. So ultimately, even if there were a variety of products, some questionable, within a code, you still had a clinical gatekeeper that said, ‘No, we want this within the code.’ The provider was risking their livelihood if they did not meet the clinician’s recommended desires.

“Competitive bidding turns that on its head. Now, you’ve got a bidding program where Medicare asks you to bid a code. And the low bid wins. You are taking a lot of the clout out of the hands of the clinicians because the clinician can’t say, ‘Fine, I’ll go to the DME down the street,’ because [that provider] didn’t win.”

Cushion codes are a big topic, one not swiftly or easily solved. But McCausland was still asked: Bottom line, what reforms would he want to see?

“We need to make sure that from the manufacturers, from the providers, certainly from the governmental contractors that are assigning products to codes, that items do meet the requirements in order to be assigned to a code, and we don’t bastardize codes by allowing products in there that don’t meet the minimum specs that exist today,” he said. “I would tighten up the minimum criteria, I would make sure the contractors were enforcing those criteria, I would take away a manufacturer’s right to self-certify their test results, which is another thing that causes weakness. If I do those three things, I have raised the bar a lot. We would be a long way toward providing beneficiaries with at least some minimal assurance that the products they’re getting are going to address their clinical needs, last for the period of time they need it and not cause them any sort of a danger.”

Stanley was asked the same question.

“I would say better defined [codes], more specific, so you have requirements so all the manufacturers are on the same playing field and what’s being provided for the money is similar, and then it becomes a little easier for clinicians to understand,” she said. “You’ve got codes and you’ve got coverage policy, and it all follows each other then.”

And she would like an industry cushion test to show the differences between macro and micro adjustability, and how they help the client. That might make CMS more willing to refine those adjustability codes.

“I personally think,” Stanley said, “that it’s real important for us to do that before CMS starts saying, ‘Wait a minute, what’s the difference in these? Because the price differential is meaningful, so how do we know it makes a difference?’ I think we need to be stepping up and addressing that prior to it being a concern.

“When you’re already being attacked is not the best time to come up with your best strategy. You’re never going to be very successful when you’re already behind.”

This article originally appeared in the August 2016 issue of Mobility Management.