What a time to be working in Complex Rehab Technology (CRT)! Or in my case, what a time to be covering it!
In about the last month, the CRT industry was told of two policy changes that could significantly change seating and wheeled mobility for the better, if the execution is solid. (That’s a big if, I realize.)
First: The Centers for Medicare & Medicaid Services (CMS) announced changes to the convoluted, repetitive requirements needed to provide replacement wheelchairs when the wheelchairs have reached the end of their reasonable, useful lifetimes (RUL).
Second: CMS’s DME MAC contractors announced they’d removed the ICD-10 code requirement for wheelchair seating.
These changes hold enormous power to both speed up the wheelchair/seating provision process and get the optimal equipment to clients.
With that power, of course, comes great responsibility. So let’s take the changes one at a time.
New rules for replacing wheelchairs
First up, the reduction of the number of hoops to jump through when replacing a wheelchair due to the end of its RUL — specifically, when replacement devices/components are expected to have the same HCPCS codes as the devices/components being retired.
Streamlining is reasonable and potentially very helpful when we’re replacing CRT that was approved in the past. That means the medical justification, supporting documentation, prescription, etc., all passed muster years ago.
CRT professionals know that wheelchair provision is slower than we’d like because the process can bog down in so many places. And that starts with the face-to-face visit with the prescribing physician.
That face-to-face is valid for a first-time wheelchair rider. But maybe a comprehensive work-up isn’t needed when we’re replacing a wheelchair that was already approved once. The medical conditions that bring clients into the CRT industry do not heal. They do not improve, though many progress — more on that coming up.
As for that face-to-face process: Tamara Kittelson, MS, OTR/L, ATP/SMS, executive director of the National Clinician Task Force (CTF) said, “I would agree for the face-to-face with the doctor that [streamlining the process] is a timesaver, because for me it was often pulling teeth to get those done correctly.
“Where I practiced in western Montana, everybody had different doctors. It wasn’t like I was in a clinic, where there was a physiatrist who knew how to do these things. So sometimes I would have to have them redone one or two times before they finally got it right. And that certainly was a delay. Getting rid of the face-to-face for replacements is a good idea.”
However, Tamara and her CTF colleagues are very concerned about another change — eliminating the clinical evaluation when providing replacement wheelchairs.
Here’s where a good intention collides with the reality of the human condition. When I was newer to the industry — and younger as a human — I thought the highest compliment was a client rolling into clinic and saying, “I want exactly the same wheelchair; don’t change a thing!”
How gratifying that the seating and wheelchair system you worked to so hard to choose, fit, configure and fine tune was so successful!
But five years is a long time between assessments. Spinal cord injuries and cerebral palsy don’t progress according to medical definitions, but humans sure do. Our bodies and minds, our vision and hearing, etc., are always changing. As I’ve gotten older, I’ve noticed that in some tough weeks, I feel differently on Friday than I did bounding out of bed the previous Monday.
Which is why the CTF sent a Sept. 24 letter to the Centers for Medicare & Medicaid Services (CMS) voicing concerns over changes to Medicare’s five-year replacement prior authorization rules for power mobility devices (PMDs).
Why a new assessment is vital
“The changes eliminate the requirement for a specialty licensed certified medical professional (LCMP) evaluation when a user is replacing a PMD with equipment under the same HCPCS code set previously ordered,” the letter, signed by Tamara, said. “We recognize and appreciate CMS’s efforts to reduce administrative burden and improve efficiency in provision of certain types of durable medical equipment (DME). But we are concerned about unintended consequences when this policy shift is applied to Complex Rehabilitation Technology (CRT) as well as some types of DME.”
The letter details the many reasons for needing a seating assessment after five years, from postural changes to changes that are part of the natural aging process, to newer, more functional seating and wheeled mobility systems or components being available.
Tamara suggested there could be middle ground between a full assessment as detailed as the original one and no assessment at all.
“I can see the benefits of, if it’s a replacement, talking about not having to justify every specific little thing — but there is supposed to be some medical documentation of continued need, that the person still has the condition,” she said. “Then have a check-in with a seating therapist. Maybe the paperwork doesn’t have to be as long, as detailed as it was before. But check in. You know, people may be surprised to hear about this new kind of cushion: ‘I think it might work for you. Let’s talk about it.’”
Sometimes, a new assessment is needed for a very basic reason.
“People have a chair they just love, and they don’t realize that it’s no longer being manufactured,” Tamara said. “This specific [chair] that they have is no longer being made under that range of code sets.”
In other cases, HCPCS codes are so broad in definition that they include products with vastly different designs and nuanced benefits. “We all know that HCPCS codes can cover a whole lot of things,” Tamara said. “You could have the same HCPCS code for a foot strap and a shoe holder, and those are two very different things.”
Preserving the benefits of a collaborative assessment
Ideally, those subsequent seating clinic assessments “could really be collaborative,” Tamara said. “Wow, you like what you’ve got. Tell me what is working and what you don’t want to see changed. Let’s do a quick mat eval to see how physically you might have changed, and then let’s see what we can do to keep you as happy in your new wheelchair as you are in your old one.”
So recurring seating evals don’t have to be a tug of war between a client who wants no changes and a therapist who wants to make significant changes.
Instead, Tamara suggested, “You ask questions that are a little more detailed, like, ‘Tell me how your fatigue level is. What are you doing these days? Are you getting too tired when you’re having a long day? Ask specifics about pain, about their home environment.”
Maybe these later assessments don’t have to be as intensely fact finding as the first one, “but there can be posture changes that are pretty subtle that maybe they haven’t even noticed,” Tamara said. “I’ve learned over the years that people who get used to leaning over to one side start to think that they are centered. And when you bring them to midline, they feel like they’re not at midline. Things like that are slow, subtle, incremental little changes that happen over a long period of time.”
ICD-10 code requirement eliminated
Serendipitously, just days before Tamara and I were scheduled to chat, the Medicare DME MAC contractors announced they had removed ICD-10 diagnosis codes from their wheelchair seating requirements.
Of course, CRT is nothing if not complex — so even a liberating change like this has a flip side.
The good: Clinicians can recommend seating based on a client’s presentation and functional needs, regardless of that client’s diagnosis, since seating is no longer tied to diagnoses.
A possible problem: Tying a seating code to a diagnosis provided a “shortcut” for professionals less familiar with — or wanting to skip — the work of a full evaluation. Not sure what seating a client with spina bifida needs? Just match the ICD-10 code for spina bifida to the list of seating products deemed acceptable for that patient group.
“Now,” Tamara said, ”you really do have to justify based on the presentation of the person, not just some diagnosis code. What is it that they are going to qualify for in terms of funding? I think that just substantiates the importance of the clinical evaluation.”
The good news is that if a client, for example, needs tilt in space and the clinician can justify it — great! No need to worry anymore whether the client’s diagnosis is among those approved for tilt in space.
“I had one young man who had a very complicated congenital condition that involved multiple organs,” Tamara said. “He had no femur on his right side, but he had a tibia and fibula and a foot sort of attached to his hip. A very unusual presentation. His diagnosis was not in the ICD-10 codes, so I couldn’t get funding for him for a custom molded cushion.”
Fortunately, Tamara was able to eventually secure funding from a grant after Medicare denied coverage. But that’s not the optimal use of time, and certainly not optimally efficient.
Tamara added that without ICD-10 code lists to lean on, clinicians less familiar with seating could find the provision process more difficult.
“That’s the rub,” she acknowledged. “It’s a double-edged sword. We know there are therapists out there who only do [seating assessments] once in a while, who don’t feel comfortable in their knowledge, who are overly dependent on the supplier ATP [Assistive Technology Professional] for what they should be [recommending] for that person.
“We know that’s happening all the time, and that’s one of the reasons the CTF continues to push for education and training and mentoring to try to help people become more confident.”
Even good changes require adaptations and adjustments. But thanks to these recent policy changes, maybe it’s a slightly easier push to get your clients the seating and wheeled mobility that’s best for them.
Which is everything we wanted in the first place.
