Reimbursement & the E1161 Code Dichotomy
The E1161 code is “Manual adult size wheelchair, includes tilt in space,” which sounds simple. But the population that uses E1161 wheelchairs has a wide range of diagnoses and presentations.
Even in an industry that is complex by definition, the broadness of the current E1161 code can be challenging to understand and justify to payors.
Code Descriptor Change
Rita Stanley, VP of Government Relations for Sunrise Medical, explained why the E1161 code is a complicated one.
“When CMS made the decision to move products out of the K0009 ‘Other Manual Wheelchair Base’ category, the decision was made to change the code descriptor for E1161 from requiring the ability to tilt the frame of the wheelchair greater than or equal to 40° from horizontal while maintaining the same back-to-seat angle, to greater than or equal to 20° from horizontal,” she said. “If you review the evidence related to tilt as it relates to pressure relief, skin protection, etc., you see why this change added complexity to developing a coverage policy, documenting medical necessity, and ensuring access to the most appropriate technology.”
So how does this translate to day-to-day operations for a complex rehab seating and wheeled mobility team? Wheelchairs with the E1161 code can vary widely in function — such as regarding how much tilt they offer — which means the consumers using the chairs can widely vary in diagnosis and function as well.
For instance, a consumer who has had a stroke, but is still cognitively and physically able to self propel within his/her living environment and independently perform mobility-related activities of daily living, could be provided with an E1161 chair.
So could an adult with a severe brain injury who is completely dependent on caregivers for mobility, bathing, dressing, preparing meals, etc.
Capped Rental Complexities
Further complicating the E1161 code is its capped rental status with Medicare.
“In 2014 CMS moved the E1161 to the capped rental category,” Stanley said. “As a result, some suppliers are not as willing to order highly individualized products because they may find themselves in a situation where the user has a stay in an acute care, sub-acute, rehab or SNF [skilled nursing facility]. When this occurs, the supplier must stop billing for the wheelchair if it is still in the 13-month rental period. The supplier is supposed to pick up the chair — few do, because there could be seating on it that the person owns, not to mention the cost of picking it up, storing it and then re-delivering it when/if the person returns home or to a home setting.”
The breadth of the current code description can make it more difficult to get funding for higher-cost chairs in the E1161 category.
“As with most of the CRT manual wheelchair codes, not all products within the codes are the same in terms of the features and options provided, and based on the different clinical applications for the various degrees of tilt, it is appropriate for the different products to offer different options,” she said. “For example, a wheelchair with lower levels of tilt is more likely (but not always) to be used by a person who can self-propel, while the higher levels of tilt are more than likely used by someone who is dependent.
“This does not mean there haven’t been improvements [to E1161 wheelchairs], only that it is hard for suppliers/clinicians and consumers to benefit from the technological changes because of funding issues. The product changes in the lower levels of products [are] aimed at the population of people who previously may have been put in a K0004 wheelchair. But the adjusted pricing for that code eliminated access to the higher-level chairs in that code.”
This article originally appeared in the April 2019 issue of Mobility Management.