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The Adjustable Cushion Code Quandary

Products Within a Code Don't Always Aptly Compare

small and large red apples

APPLES: ISTOCKPHOTO.COM/DELFINKINA

Inclusion is an important goal in the complex rehab technology (CRT) industry. Innovative seating and wheeled mobility recommended, built and fitted by expert clinicians and providers can support new levels of independence and participation for consumers.

But inclusion can hinder access to CRT when it’s applied too widely to Healthcare Common Procedure Coding System (HCPCS) codes, those letter-number combinations intended, according to the Centers for Medicare & Medicaid Services (CMS), “primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office.”

Many CRT experts believe adjustable wheelchair seat cushion codes are too inclusive, with definitions so broad that large numbers of products apply, even though the products demonstrate varying levels of functionality and don’t allow an “apples to apples” comparison. Such widely inclusive codes can impact many facets of CRT, from reimbursement to product innovation, clinical outcomes and consumer access.

What’s the Goal of a HCPCS Code?

The four adjustable cushion codes are E2622 (skin protection, adjustable, width less than 22", any depth); E2623 (skin protection, adjustable, width 22" or greater, any depth); E2624 (skin protection and positioning, adjustable, width less than 22", any depth); and E2625 (skin protection and positioning, adjustable, width 22" or greater, any depth).

Rita Stanley is VP of Government Relations for Sunrise Medical. She is one of the industry’s most highly regarded and experienced experts on HCPCS coding, coverage policy and funding, and she has a long history of addressing codes that the CRT industry believes are too broad. That includes the adjustable seat cushion codes.

When it comes to widely inclusive codes, Stanley thinks the problem starts at a very elementary level, with varying perceptions of why HCPCS codes exist and what they’re supposed to accomplish.

“It starts at the assumption of ‘What is a HCPCS code and why is it used?’” Stanley said. “I believe that [CMS] thinks HCPCS codes, due to regulation or legislation, cannot consider how coding impacts coverage and payment when CMS is assessing code applications. In their minds — and they’ve said this any number of times to me — HCPCS codes are purely a billing mechanism.”

Granted, HCPCS codes are used on CRT insurance claims. But that’s just one way they’re used.

“The reality is [the codes] are also how coverage is developed,” Stanley said. “It’s how payment is developed, and if you don’t delineate product properly [within the codes], you have no way of tracking utilization.”

Comparing Like Products

Tracking utilization — knowing which CRT products are being provided and used — is critical to measuring patient outcomes. But when a HCPCS code is so broad that it includes a number of products with varying abilities and functions, it’s impossible to determine which, if any, of the products are delivering desirable results.

Right now, Stanley pointed out, payors “can tell you how many times that code was billed, but they cannot tell you anything about what was provided within that code. You have no way whatsoever of tracking outcomes for patients based on the range of technology that’s within a single code, and it creates enormous burdens to do research that would demonstrate the efficacy of certain products for various patient populations. You can’t test one code to the next. You would literally have to test every single product against every [other] product inside the same HCPCS code. That’s unsustainable, and nobody could afford it in our industry because the industry is just too small.”

The Start of Adjustable Cushion Codes

The adjustable seat cushion codes in use today were born from the best of intentions. In the early 2000s, Stanley said, CMS set out to create a set of seat cushion codes that would work better than the single code being used at that time.

“Dr. [Kenneth] Nelson and Dr. [Doran] Edwards had both put in a considerable amount of time looking at the products and thinking about how to verify that the products were even effective, because there was no way to test them or measure them, or no requirement for testing,” Stanley said. “They had worked closely with RESNA on the standards regarding cushion testing, and part of the problem was the limited number and types of tests that were established for cushions. (See sidebar.) It takes a long time to develop product standards and test criteria, and for those to be accepted as ANSI RESNA requirements. It’s not something that can be accomplished in six months. The process is very thoughtful, a lot of people serve on the standards committees, recommendations go through multiple rounds of comments and edits, and it’s a long and thoughtful process.”

The Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC), which preceded the PDAC, “had created an initial code set for wheelchair seats and set fee schedules for them,” Stanley said. “Because of the pricing methodology, it immediately took the higher-end, more effective cushions — even those shown in evidence to be more effective — and threw them out of the realm of being able to be provided. And so there was a really fast, very loud outcry from the clinical community and the industry, as well as consumers. And CMS immediately responded. They recognized they had a problem.”

CMS, according to Stanley, also realized it had to develop a resolution quickly. Consumers were being provided with cushions during this period, of course, and those consumers could be stuck with ineffective cushions for quite some time, given the replacement policies in place.

“Unfortunately, there was not enough time to go back and say, ‘How do we resolve this? How do we create tests that can demonstrate what the true differences are in how these products function?’” Stanley noted. “Because functionality is just not built into the HCPCS code set.

“So they looked for technological differences among the products in the problematic codes. Then a definition was created for adjustable, which was the ability to add or remove material after delivery and in the field. It provided an opportunity to get the more functional products moved out of the problematic codes, and [CMS] applied the [miscellaneous] K0108 code to those products for a while until they had a chance to create new codes. But unfortunately, that new definition also moved over some products that were not of the same caliber. The products in the adjustable skin protection and the adjustable skin protection and positioning codes are not equal.”

The initial intent was to provide a temporary solution until better-researched product distinctions could be identified. But that’s not what ultimately happened.

“At that time,” Stanley said, “there was talk of “Let’s do this now, let’s at least give this an immediate kind of resolution, and then we’ll start working with RESNA, we’ll work with some of the other research and academia folks, and we’ll try to figure out what the key differences are. What are the features of these products that make them distinct in terms of how they help treat and reduce skin injuries? When we have good tests that we can apply and we have really good definitions, then we’ll create new codes for the adjustable [cushions]. Until then, this will be a good Band-Aid.”

But then the SADMERC contract ended and gave way to the new PDAC, and the plan to develop new codes for adjustable cushions never materialized.

“So if you fast forward to where we are right now,” Stanley said, “we have adjustable skin protection and adjustable skin protection and positioning codes, but they’re still being defined as those products where you can add or remove material. And in the research about skin protection or the ability to assist in healing wounds after they’ve occurred, there’s no evidence that says the most important thing is that you can add or remove material. There is a lot in the research that studies the material of the cushion itself, and when the material is a fluid, how that fluid reacts — not only how it works with the client just in sitting in their wheelchair, but as they move in their wheelchair, as they reach for objects, as they reposition, as they go about their day. There’s a real difference in how fluid reacts.”

The Impact of Current Cushion Coding

The effect of the adjustable cushion codes’ broad inclusivity is far reaching. For instance, products within a single code are treated as comparable from a reimbursement standpoint, though in reality, the products within a code can be vastly different from each other in design, materials used, functional goals and clinical outcomes.

As a metaphor, Stanley said, “Let’s say you’re going shopping for a stove. You love to cook and bake, and you say, “I think I really want a Viking.” Well, if in the store it was ‘Oven, any type,’ and the store took all the ovens they carried and arranged them in descending order based on price and picked the middle number and said, ‘Here’s what an oven in our store costs, whether you’re buying a toaster oven or you’re buying a Viking oven,’ how many people do you think they’re going to let walk out of their store with a $10,000 Viking at $1,000? And how many people do you think are going to appreciate paying $1,000 for a toaster oven? A toaster oven is great if all you’re doing is toasting bread. But if you’re making homemade bread and you need to proof it and have it rise and all the things that have to happen to produce artisan bread, then you’re going to want to invest in that oven.

“And that example isn’t about medical need. HCPCS codes allow or deny access to medically necessary technology. What [CMS] has done is not only have they said, “We’re taking products with totally different functions, totally different technology intended for a totally different population of people, and we’re going to put them into one single code with one single payment amount,” but also, “Oh by the way, you can’t even do a patient upgrade because these technologies are in the same HCPCS code, and upgrades within the same HCPCS codes are not allowed. So in this situation, consumers can’t obtain the needed item unless the supplier provides it non-assigned, the consumer pays for it out of pocket, and then is reimbursed by Medicare [at] 80 percent of the allowed amount. CMS has created a scenario that has made access very challenging and only for those beneficiaries who can afford to pay out of their own pocket.”

A wheelchair user’s inability to obtain the cushion that offers the best clinical outcomes can be dire.

“Unfortunately, when a cushion fails for an individual, the implications and consequences are significant,” Stanley noted. “Once you have skin injury, whether it’s healed or how long it’s healed, you are now at a much higher risk than if you had not had that skin injury. So the impact of that, financially — because of the expense of healing wounds — and also the pain and suffering of the consumer, are fairly easy to measure. This is [a product group] that should be easily measurable if they would allow somebody to go through and do what we did years ago, which is to bring the technical experts to the HCPCS coding people and have collaboration that says, ‘We’re all after the same thing here.’”

Technology & HCPCS Code Creation

While payors might view HCPCS codes largely or solely from a number-on-a-claim perspective, product development and design are deeply impacted by code definitions.

“There are literally hundreds of examples where the CMS work group has gone back in, after a manufacturer has submitted for a code application, and made a decision to change the code descriptor to say ‘Any type’ so more and more technology could get shoved into a single HCPCS code,” Stanley said. “A more recent strategy is to say, ‘All of that is included in the base price of the wheelchair, so we’re going to change the code descriptor to Replacement only. You can only bill for it when you go to replace it.’

“You can no longer bill for it at initial issue. That includes any special handrims, dynamic backs, or [Sunrise Medical’s] mono back. There are some really innovative technologies [about which] CMS has said, ‘That’s already included in the base price of the wheelchair.’” This [technology] didn’t even exist when they created the wheelchair codes or developed the fee schedules. How could it be included in the base price? But that’s the kind of decision that’s been coming out of that work group for the last decade.”

That funding environment — where innovative products with new functionalities are lumped together with older, less effective products in the same code with the same allowable — can discourage manufacturers from developing products that could result in better patient outcomes. Research and development is expensive; why bother if the manufacturer will end up losing money on those resulting products because allowables are still being based on older, less functional technology?

From a profitability standpoint, the alternative is for manufacturers to make products that fit existing code requirements and are less expensive to produce. But that removes any motivation for manufacturers to be innovative with new product designs that could improve patient outcomes and their quality of life.

“HCPCS codes need to be based on technological difference and functional difference,” Stanley suggested. “Not that [a manufacturer] can just claim [their] product is better and somehow get a different code. But if I can demonstrate that my product is different in material, technology or design, and those changes have a relevant, possibly observable impact on the population of intended users that we identified when we designed that product, and I’ve designed this product to address a need that’s not addressed by the products that are currently coded — then I should be able to get a unique code for that.

“With many technologies the patient-specific outcome is observable; [the product] meets the medical or functional need, or it doesn’t. If I can demonstrate, through observation of the product or scientific evidence of the product — maybe case studies where clinicians have trialed products with patients or followed patient outcomes for an appropriate period of time or done comparative effectiveness studies to see which products answered the patient’s identified medical and functional needs — and I can demonstrate that the products are different and have a different outcome, I should be able to obtain a unique HCPCS code to ensure access, so that the payors can create coverage policies around these products and the population of people they serve.”

What today’s CRT users don’t need, Stanley said, is just more of the same technology for years to come.

“There are already tons of products that fit the codes,” she said. “The only advantage that a manufacturer can really bring is if they can innovate to meet unmet medical needs. But if you’re going to shove [an innovative new product] into the existing code with the same existing allowable, [manufacturers] have zero incentive to be innovative. And they can’t build innovative technology when there is an artificial allowable constraint.”

Reimbursement is also a problem for CRT providers who, by nature of the consumers they work with, deal almost entirely with higher-end technology.

“There is an assumption made by some at CMS,” Stanley said, “that if all the products are in the same code and we’ve got this allowable, sometimes a supplier is going to make a decent allowable, sometimes they’re going to lose money. Hopefully, at the end of the day, it comes out equal.

green apples

APPLE: FLICKR/ANDY WHITTLE

“The problem with that theory is suppliers that are providing the standard product are not typically the same suppliers who are doing the majority of the CRT. So the supplier who does complex rehab all day long never sells enough of the product that he makes margin on to make up for the products he loses money on. So he’s losing money almost every single time.”

Many Stakeholders, One Goal

If there’s a bright spot in the ongoing challenge of adjustable seat cushion codes, it’s this: Aligning the HCPCS codes with function and outcomes would benefit all involved parties.

“All stakeholders win in a scenario where HCPCS codes are established based on technological and functional differences and their benefits to consumers, and then payment and coverage are all associated with that properly,” Stanley pointed out. “The payor is paying for what the consumer is receiving. Consumers are getting what they need. And you’ve even promoted the economic side of it: Manufacturers are going to develop innovative products that meet unmet medical needs.”

For that to happen, Stanley believes that a product’s functions and features need to be part of the code that’s being created.

“The model needs to change, with technological differences and the functionality and features [becoming] the basis for coding,” she said. “For headrests alone, you could easily have five or six different codes that would represent the array of headrest technology. You could go through each of the HCPCS codes and clearly identify features and functions: What are those technological differences that are relevant, and why are they relevant, and who are they relevant for?

“If that were the basis of the HCPCS code set, you would see a very different outcome for every single stakeholder, including payors. Then if they decide to competitively bid the standard technology, at least everybody is bidding on the same features and functions. It may not be the exact same cushion, but at least the minimal standards are consistent, and you don’t have a whole array of product that exceeds the minimum requirements, but nobody can obtain it because of the cost.”

In that model, products within a code would all have comparable features and functions to serve a common patient population. Manufacturers could choose to differentiate their products in other ways, such as by improving aesthetics.

“If I want to add features that make it preferable to a consumer, but aren’t a medical necessity — if I make mine weigh five ounces less, or I paint it some new funky color of pink — that’s something that becomes patient choice and becomes a manufacturer’s prerogative, and we compete in those different ways,” Stanley said. “But when it comes to medical necessity, patients shouldn’t have to pay out of pocket. That should be something covered by their insurer, whoever their insurer is.”

This article originally appeared in the January 2019 issue of Mobility Management.

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