How a Separate Benefit Category Could Help CRT Codes

US CapitolThe complex rehab technology (CRT) industry has been working toward establishing a separate Medicare benefit category for seating and wheeled mobility equipment used by people with severe, permanent and sometimes progressive mobility-related conditions.

Would establishing a separate Medicare benefit for CRT — one distinct from the durable medical equipment (DME) benefit — help with CRT’s ongoing coding problems?

Rita Stanley, VP of government relations for Sunrise Medical, says yes.

The Needs of the 8 Million

The difference between Medicare beneficiaries who use CRT and those who use DME is at the heart of why the separate benefit category is needed, Stanley explained.

“The genesis of the separate benefit category,” she said, “was the realization that as long as all of the policies that Medicare is developing — coding, coverage, payment — are really geared toward the 80 percent of the Medicare population people — toward the 48 million versus the 8 million [who use CRT] — then we’re always going to be in this vicious cycle. Because when you write policy centered around aging, frail, acute illness kinds of things, you’re not writing policies that are particularly friendly toward people with permanent disabilities. And that’s where we’ve constantly had this battle. Our people are different.”

Stanley pointed out that distinguishing beneficiaries who use Medicare because they’re seniors from beneficiaries who use Medicare due to disability could also benefit the agency.

“So with the separate benefit category, we’re saying, ‘This is good for you, too, Medicare, because now you’ve got a solid line that says your 48 million people that are over 65 sit in that bucket and they use DME, and you can write all your policies around that population of people.”

Beneficiaries who use Medicare because they have serious disabilities have different needs and goals, Stanley said.

“Our population of people on the [CRT] side of the line are people that may be over 65, but they also might be 35 or 40, and they’re eligible purely based on their disability,” she said. “And those people are going to have a whole separate set of codes, coverage and payment policies that specifically support their medical needs and functional needs. It addresses the coding issue, the payment issue, equipment and long-term care.”

Creating a separate benefit category for CRT would also remove CRT users from Medicare’s controversial policy of only considering beneficiaries’ needs within their homes, not outside of it.

“[The separate benefit] addresses the in-the-home problem,” Stanley said. “You don’t tell a 35-year-old person who’s trying to take care of children or trying to work, ‘I’m only going to provide you equipment that gets around inside your home.’ You make sure they have access to the community as well.”

Starting with a Blank Slate

Stanley said the language in separate benefit category bills that have been put before Congress is very specific.

“It’s very clear what Congress’s intent is,” she said. “The intent is to have policies that treat the population of people with disabilities in an appropriate manner. And it wipes the slate clean. It doesn’t say we’re going to continue to put Band-Aids on top of a broken process. It says, ‘We’re going to pull these people out, we’re going to pull this [CRT] equipment out, and we’re going to put safeguards in place that say only the people that really know what they’re doing can even address the equipment needs of this population.”

The new benefit category would have its own HCPCS codes, and the accompanying definitions and descriptions would at last compare similar CRT products, rather than lumping those products with DME products that have significantly different applications.

When products intended for CRT clients are grouped, coded and priced together with much less fully functional DME products (see the foot box sidebar), Stanley pointed out that the resulting allowables often put CRT items financially out of reach.

“If you look at the population of people with complex disabilities that need CRT, that population is [so small] in comparison to general Medicare,” she said. “So the array of products available that are standard, basic products — there’s a ton of them.”

Stanley said that when she collected pricing data for CRT foot boxes, she found a handful of manufacturers who produced them. There were only a few CRT foot boxes available compared to the litany of DME positioning straps that were in the same code as the foot boxes.

That’s problematic because of how CMS calculates allowables. Stanley said the agency listed all of the products within the code, from the highest priced item to the lowest, then chose the product that literally sat in the middle of the list. That product’s price was used as the basis to begin calculating the allowable.

Because there were so few foot boxes on the list compared to the massive number of straps, the list’s “middle” product wasn’t a foot box; it was a strap. The price of that strap was used to calculate the reimbursable amount for a CRT foot box that’s much more fully functional — and much more costly to produce.

“They use the median product,” Stanley said of how CMS chose the price to work with. “So it doesn’t have anything to do with the amount [the product costs]. If you list them all, highest to lowest, and pick the middle [product] from the list, the odds of any of our CRT items ever being the median product is almost zero. Then [CMS] deflates it using the current deflation rate, and then they reinflate it back to today with at least 10 years of CPI [Consumer Price Index] freeze. So when you take an item and cut it to less than half, and it’s already an item that’s substantially below the retail of any of the higher-end, more fully featured functional products, and then you can’t even reinflate it to current day — you’re toast.”

Compare that current scenario with one that could take place once the separate benefit category is in place. Foot boxes could have their own code, and the code would contain not heel loops or leg straps, but only foot boxes.

Since foot boxes are products used only in CRT — because typical DME wheelchair users don’t need them — the new code would contain only foot boxes made by CRT manufacturers. While manufacturers’ foot boxes would vary slightly in price, “it’s not thousands or hundreds of dollars,” Stanley said. Pricing among the foot boxes would be similar enough that if CMS listed the products and chose the “median” foot box, the resulting allowable shouldn’t put it out of a client’s financial reach. Access to CRT wouldn’t be routinely threatened the way it is today when CRT products are inaccurately grouped with DME ones.

And CRT manufacturers would be able to innovate and develop new, more fully featured products for consumers with severe disabilities without worrying about having to compete, pricing wise, with standard DME.

Of current coding policies, Stanley said, “[CMS] puts barriers in place that make a manufacturer say, ‘It’s too much risk. I’m going to make a foot box and they’re going to price it as a toe loop/heel loop/leg strap, and I can’t do it. I’m going to spend all this money to develop a product and bring it to market to find out I can’t get a code, I can’t get payment, I can’t get coverage.”

That dilemma is ultimately suffered by the consumer, who ends up with less functional equipment and loses the ability to live more independently.

“There’s equipment that might help them do that,” Stanley said, “but [consumers] are being denied access to it, whether it’s intentional or unintentional. It’s occurring because of the coding and payment structure.”

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

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