Cushion Codes: Where We Stand Now

Wheelchair seat cushion testing, standards, codes and reimbursement are multiple sides of the same coin…if a coin had about a dozen different sides. Assigning appropriate codes to cushions is necessary for adequate reimbursement. Defining codes is necessary to understand which cushions belong within them. Testing cushions determines the codes they should have. Determining the standards cushions should meet, such as how many test cycles they need to survive, helps to define what clinicians, ATPs and consumers should expect from different cushions.

It’s a complex relationship with a long history, said Rita Stanley, VP of government relations at Sunrise Medical.

“New seating codes were implemented in 2004,” she said. “One of the primary goals at that time was to address the fact that there was a single code: E0192, Low Pressure and Positioning Equalization Pad. The SADMERC, a Medicare contractor prior to the [current] PDAC, requested new HCPCS codes to represent the high number of products in the E0192 and the myriad array of technology and varying efficacies for addressing skin injuries or positioning.”

Stanley said stakeholders spent years on the coding proposal.

“The Medical Directors (this project spanned more than one) worked with several experts and the RESNA product standards board to link product testing to the new codes with the goal of ensuring product quality and efficacy to the extent possible. There were limitations in terms of testing, and as hard as the RESNA board and researchers worked to establish tests to demonstrate a product’s ability to provide skin protection, time ran out.

“The codes were announced and implemented; the result was that a wide array of skin protection products remained grouped into one code, and the initial fee schedule was inadequate to allow access to fluid technology, the technology with a history of reliability and what clinicians depended on for people at high risk or with a history of skin injuries. The SADMERC and CMS promptly responded and created a distinction with the skin protection code for ‘adjustable’ and allowed products with the capability of adding or removing material after delivery.”

Stanley said stakeholders recognized this as “not the best solution, only the most expeditious one, and there was a commitment to continue to consider a way to define the important cushion materials and characteristics that would distinguish the various levels of skin protection technology. In addition, the SADMERC agreed to continue to work with researchers and RESNA to develop tests to demonstrate the abilities of cushions to meet any newly developed criterion.”

Then, the SADMERC lost the Medicare contract, and the cushion provision wasn’t included in the PDAC contract.

“Changes to the initial codes created in 2004 have not happened,” Stanley said. “As a result, the number of models that have been coded under E2603 (skin protection seat cushion, width less than 22", any depth) and E2622 (adjustable skin protection seat cushion, width less than 22", any depth) since these codes were implemented is approximately 1,700 and 1,400, respectively. Not all of these models are valid for billing under these codes today, but there are still a high number of products that are, and there is little meaningful code distinction between these models, while the actual technology differences and efficacy varies. Moreover, the coverage requirements are the same. This makes it difficult for inexperienced clinicians or consumers of this technology to make educated decisions regarding the most appropriate technology in a given situation.”

So, inexact coding and inappropriate product assignments within cushion codes continue. “As efforts to control utilization and cost has become a priority for payors, having HCPCS codes, definitions and defined characteristics is more important than ever,” Stanley said.

This article originally appeared in the May 2017 issue of Mobility Management.

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