Coding Conundrum: When a Foot Is Not a Foot?

happy footOn the surface, HCPCS coding would seem to be a way to bring order to the enormous number of complex rehab technology (CRT) products available, from seating and wheelchairs to the components and positioning options that create optimal support.

But when HCPCS codes are “stretched” to cover applications not originally intended — and not clinically or functionally supported — a system that is supposed to bring order and efficiency can produce quite the opposite effect.

Billing by the Foot

For example, consider the complicated coding history of the wheelchair foot box.

A number of CRT manufacturers produce foot boxes, including Sunrise Medical, whose online description says its foot box line is “designed to protect the lower extremities from injury and skin breakdown resulting from periods of high tone.” At press time, other CRT manufacturers offering foot boxes included Adaptive Engineering Lab (AEL), Comfort Company and Therafin Corp.

Rita Stanley is Sunrise Medical’s VP of Government Relations. As an example of how convoluted the coding process can become, she raised the issue of foot boxes, for which the CRT industry requested a HCPCS code from the Centers for Medicare & Medicaid Services (CMS).

“We asked for three codes,” Stanley said. “Two of the codes we asked for were pre-fabricated [foot boxes]; one was for custom.”

CMS responded by granting a single code: E0954, defined as “Wheelchair accessory, foot box, any type, includes attachment and mounting hardware, each foot.”

“[CMS] said, ‘We’ll say, ‘any type,’” Stanley noted. “So now we’ve got pre-fabricated product and custom-fabricated product all under one single code. Because we asked for a single, a full with or without dividers, and custom, they said, ‘We’ll give you one code, and you get to bill for the number of feet.’ That’s a first for me. I’ve seen Each and I’ve seen Pair; I’ve never seen billing per foot. But if you’ve got a client with two feet and you’re putting them into one [foot box] unit, you get to bill for two feet.”

A Toe Loop, a Heel Loop & a Leg Strap

Initially, Stanley said, industry members who’d been working on getting codes for foot boxes hoped they could work with the single code they’d been given.

“What we all sort of said was: Let’s not panic yet. We’ve got a code, which is more than we had. Let’s see what the fee schedule comes out as,” Stanley recalled. “I know how they calculate the fee schedule, and I was expecting it to come in at around $200.”

Then came another blow.

“[CMS] said, ‘A toe loop plus a heel loop plus a leg strap is comparable to a foot box.’ So they took competitively bid prices for those three straps and said they were comparable even to a custom-fabricated foot box. And the fee schedule is less than $50 per unit billed.”

Toe loops and heel loops are essentially webbed, relatively narrow, fabric straps. Even at first glance, they look drastically different than a foot box, which typically has a bottom, a top and multiple sides — just as its “box” name suggests.

But when it came to determining an allowable for the new foot box code, CMS considered fabric straps to be comparable items.

Stanley said she was told that during the allowable determination process, CMS had also considered using the allowable for a “wedge cushion” as the basis for determining the foot box allowable, but ultimately decided that a toe loop/heel loop/leg strap combination made more sense.

In reality, though, that comparison resulted in an allowable so low that it’s impractical.

“You essentially end up with a code where the reimbursement is so bad that [the manufacturer] can’t even make it for $50, much less [have it be possible for a provider to] get it delivered to a consumer and billed to Medicare and all those costs.

“We have a code. But there is no way anybody’s going to get that on an assigned claim.”

The Cost of Being Compared to DME

Stanley said the ongoing struggle to get foot boxes properly identified and funded demonstrates what can happen when CRT is lumped together with durable medical equipment (DME) or considered the equivalent of DME.

“Back when Doran Edwards was still with the SADMERC [as medical director], he had coded foot boxes as K0108, so you could bill MSRP and they gap filled to come up with a different price,” Stanley said. “Then when it went from SADMERC to PDAC, PDAC said, ‘No, we think that [foot box] is a calf rest pad.’ A calf rest replacement pad goes on an ELR [elevating legrest]. And we fought that for years.

“Then they made the calf rest pad code replacement only, so you couldn’t bill for a foot box at all, because it was coded as a calf rest pad, replacement only. That’s when I decided to submit an application for a new code, and I got Foot box, any type, for $50.”

If you’re thinking that the purpose of a foot box seems rather obvious, you aren’t alone. Stanley said she recently traveled to Washington, D.C., while carrying an actual foot box and three webbed straps with her.

Stanley said, “Twice, I had gentlemen say, ‘Can I get that foot box for you from the overhead?’ And I said, ‘How do you know what that is? Are you in this industry?’ And they said, ‘No, but pretty clearly, it’s a box that you put your foot in.’”

This article originally appeared in the March 2018 issue of Mobility Management.

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