Comprehending Cushion Codes

So much depends upon wheelchair seat cushions, particularly for clients with complex seating needs. An
optimal cushion in the right seating system can give its user more comfort, safety and function in his or her
wheelchair. The wrong cushion can be catastrophic.

So much therefore depends upon cushion funding, which in turn depends on a cushion’s HCPCS code.
The variables for cushions commonly used by complex rehab clients are skin protection and positioning —
used alone or together — plus adjustability. And it’s much more complicated than it sounds.

Cushion History, Revisited

To understand current cushion codes, it’s helpful to look at their history — how codes were written and why.

That means going back more than 10 years, when industry experts worked with Doran Edwards, M.D.,
medical director of Medicare’s Statistical Analysis DME Regional Carrier (SADMERC, which later became
the Pricing, Data Analysis & Coding contractor [PDAC] after a contractor change), to revise cushion codes.

Rita Stanley, Sunrise Medical’s VP of government relations, was among the industry members working
on the project.

“Part of what Dr. Edwards was doing was looking at the different technologies and trying to understand
the different materials that are used,” Stanley said. “‘Is there a difference between foam and fluid, and do I care? When do I care, and how do I know when enough is enough?’ [Edwards] reached out to RESNA; he talked to the committee
involved in developing those tests and getting those tests passed,
approved and accepted as an ANSI/RESNA test, and part of the
issue that we ran into in 2004 is there wasn’t enough time. It’s
not an easy thing to do, creating a new test and getting it signed
off by all the different people who serve on those committees and
boards. He ran out of time to have RESNA create a new test that
would test this concept of adjustability.”

When the new codes first came out, Stanley said, “There
was just skin protection, positioning, and the combination of
skin protection and positioning.” The result: Different forms of
technology with varying efficacies were in the same code and
therefore received the same reimbursement.

“Products that were fluid based, air-flow based — JAY products,
ROHO and others — were suddenly not available because
the reimbursement level for a basic skin protection cushion just
wouldn’t have allowed it,” Stanley said. “The response of the
stakeholders, whether consumers or clinicians or manufacturers
or suppliers, was pretty extreme and immediate. So I think
CMS (the Centers for Medicare & Medicaid
Services) and Dr. Edwards realized, ‘We’ve got
a problem and we’ve got to address it. But how
do we address it? Because we don’t have time
for the ANSI/RESNA test component of this.’”

Preserving Code Integrity

Skin protection wasn’t the only area that
caused concern, says J. David McCausland,
VP of planning & government affairs for
ROHO Inc. McCausland was also part of the
industry team that worked with Edwards.

“When we created the seating policy, we
felt it was important that products assigned
to codes met certain performance characteristics,
that [they] also met certain durability
characteristics, and certain safety characteristics,”
McCausland said.

The seating policy includes an immersion
test — originally developed by Stephen
Sprigle, Ph.D., PT, McCausland noted, and
also known as an “indenter” test — plus an
aging test to measure a cushion’s longevity
and a fire retardancy/safety test. But the tests
lacked certain specifics that have proven
problematic.

“The indenter test basically pushed these
cylinders, which were 40 cm long to represent
the ischials, down into the cushion to see if
they could immerse so far,” McCausland said.
“The way they were to evaluate durability is
you would then age the product. Some of the
cushions would be aged to a year; in other
situations, the cushion was to be aged to 18
months. And then you’d run the immersion
test again. The logic was Does it continue to
function after 18 months of simulated use? So
it’s not five years of durability, but at least you
know that the product continues to provide
some benefit over some period of time.

“Here’s the problem: They did not put in the policy any requirements with regards to what anybody has to do
to accelerate aging on their product. There was no description, no
minimum requirement, nothing about laundering, nothing about
repetitive loading, and nothing about heat aging. It was really
subject to interpretation, and you could have manufacturers that
perhaps were a bit too lenient in what they considered to be the
minimum aging before they’d run the test again.”

McCausland said the safety test also lacks practicality.

“We have a fire-retardancy test, but it’s the California
[Technical Bulletin] 117 test, which is basically a cigarette test.
Does it really make sense to do a test of an open flame sitting on
top of a cushion, when realistically, that’s where the person would
be sitting? You need to do fire tests or safety tests looking at the
edge or looking at something from the bottom.”

Adjustability: Macro vs. Micro Changes

In addition to skin protection and/or positioning, current
cushion codes include categories for adjustability, a concept that
Stanley said has been particularly difficult to capture.

“There had been originally a concept that adjustability had two
meanings,” Stanley said. “It was adjustable in that you could put
air in it, you could put fluid in it, and then you could take it out or
add it at a later date to adjust it. That was one way to look at it, and
that might be important if you had a person that gained weight,
lost weight, whatever the situation was that the clinician decided
in the field, ‘This isn’t meeting their needs right now.’

“The other piece of it was critically important when it comes
to skin protection. And that was Does the material have the
capacity to adjust throughout the day as the person moves or shifts
or changes how they’re sitting on that cushion? And that is a much
more difficult part of the cushion to test.”

Though clinical experts worked to develop a test that could
quantify a cushion’s ability to make “micro” adjustments
throughout the user’s day, eventually the team ran out of time.
The result, Stanley said, was cushion policy that limits adjustability
to “macro” adjustments — the ability of a skin protection
cushion to be modified after delivery to the client. Left out of the
policy: a cushion’s ability to adjust on the fly in response to weight
shifts that wheelchair users have when rolling down a ramp or
leaning to pick something up from the ground.

McCausland’s issues with the adjustability portion of policy
start with the adjustable cushion’s construction.

Examine the local coverage determination, which says,
“Wheelchair cushions containing a fluid medium — air, gas,
liquid or gel — that have the capability for the immersion characteristics
of the cushion to be altered by an addition or removal of fluid will be considered adjustable. The adjustment may be in the
manner of direct addition or removal of the fluid, e.g., adding or
removing air, or indirectly by the addition or removal of packets
of fluid. … Adjustable as applied here requires that the procedure
is capable of being performed by the beneficiary or caregiver
using the items supplied at the time of the initial issue of the
device in response to the beneficiary’s need for more or less skin
protection because of weight loss, gain or muscle tone changes.”

McCausland noted, “So that has several key points in it which I
think need to be called out. It calls out that there has to be a fluid
medium in it. That the fluid medium is specific for skin protection.
That the adjustment has to be capable of being done by the
beneficiary or caregiver in response to the beneficiary’s need for
changes over time. The whole thought of an adjustable cushion
is [the client is] going to change, so we have to make sure the
cushion can change to continue to provide them the best environment.
That’s right in the policy, and yet the PDAC over the last
few years has started coding products to the adjustable codes that
have no fluid, [just] a slab of foam.”

His point, McCausland said, was not to “bad-mouth any of
these products. They might be very good, and maybe they deserve some new coding. But we bastardize the integrity of the codes if
in fact we start assigning products that don’t meet the description
into these codes. I know we worked very hard to make sure
we had a definition that met the skin protection needs of these
individuals over time. And you can’t do that with a solid piece of
foam. It has to have a fluid that you can add or remove.”

How Codes Impact Funding

Stanley is concerned that the loose definition of adjustable —
one that takes macro, but not micro adjustability into account
— could hurt funding for cushions that do offer more complete
adjustability.

Some 12 years after the industry worked with Edwards, CMS
has “lost sight of the need to adjust that definition to also include
the adjustable characteristic of the material that the adjustable
cushion is made from,” she said. “That’s a really critical thing
that’s missing, so when people start saying, ‘How do I decide? Do
I need just a skin protection cushion, or do I need an adjustable
skin protection cushion?’ — I would suggest that people who
are most capable of making that choice do it based on their
experience as wheeled mobility and seating specialists or wound
care specialists who have observed how their patients respond
to different technologies. It’s that evidence-based practice, it’s
evidence that has been observed through years of doing it that
allows those clinicians to be knowledgeable about the technology
and how their particular patient presents. They know they need
air or they need fluid or they need this kind of material, and that’s
only likely available in an adjustable cushion code.

“It’s their understanding and knowledge and experience as
therapists and clinicians that’s going to drive them to the right
cushion. It’s not going to be based on policy or the definition of
the code as CMS has it today.”

Manufacturers who want both macro and micro adjustability
in their cushions — who “are going to genuinely develop innovative
product that makes every effort to address all the elements
that contribute to skin injury,” as Stanley said — will be challenged
by other manufacturers who take the less expensive route
of concentrating just on cushions with macro adjustability.

And there’s also the potential that CMS will take a closer look
at micro-adjustable cushions and wonder whether the extra costs
are justified — especially because adjustable cushions are not part
of Medicare’s competitive bidding program.

“Standard skin protection cushions have been in every round
of competitive bidding,” Stanley pointed out. “So as you see the
reimbursement for a standard non-adjustable skin protection
cushion go down further and further and you have more of a
delta between the adjustable and the non adjustable, that’s going
to make payors say, ‘Tell me again why I’m paying that much
more for adjustable. What is it?’ And we’re missing the ability to
demonstrate some of what’s really critical and what makes the
differences between those categories of products so important.”

McCausland agreed that competitive bidding upended what
had been an industry system of checks and balances. “For so many
years, we were used to fee-for-service structures,” he said. “Even if
you had 2,000 items assigned to a single code, if the dealer wanted
to maintain their livelihood, they had to satisfy the caregiver, the
clinicians and the end user. There’s nothing worse for a provider
than ticking off one of your referral sources. So ultimately, even if
there were a variety of products, some questionable, within a code,
you still had a clinical gatekeeper that said, ‘No, we want this within
the code.’ The provider was risking their livelihood if they did not
meet the clinician’s recommended desires.

“Competitive bidding turns that on its head.
Now, you’ve got a bidding program where
Medicare asks you to bid a code. And the low
bid wins. You are taking a lot of the clout out of
the hands of the clinicians because the clinician
can’t say, ‘Fine, I’ll go to the DME down the
street,’ because [that provider] didn’t win.”

Cushion codes are a big topic, one not swiftly
or easily solved. But McCausland was still asked:
Bottom line, what reforms would he want to see?

“We need to make sure that from the manufacturers,
from the providers, certainly from
the governmental contractors that are assigning
products to codes, that items do meet the
requirements in order to be assigned to a code,
and we don’t bastardize codes by allowing
products in there that don’t meet the minimum
specs that exist today,” he said. “I would tighten
up the minimum criteria, I would make sure
the contractors were enforcing those criteria,
I would take away a manufacturer’s right to
self-certify their test results, which is another
thing that causes weakness. If I do those three
things, I have raised the bar a lot. We would be a
long way toward providing beneficiaries with at
least some minimal assurance that the products
they’re getting are going to address their clinical
needs, last for the period of time they need it and
not cause them any sort of a danger.”

Stanley was asked the same question.

“I would say better defined [codes], more
specific, so you have requirements so all the
manufacturers are on the same playing field and
what’s being provided for the money is similar,
and then it becomes a little easier for clinicians
to understand,” she said. “You’ve got codes and
you’ve got coverage policy, and it all follows each
other then.”

And she would like an industry cushion test to
show the differences between macro and micro
adjustability, and how they help the client. That might make CMS
more willing to refine those adjustability codes.

“I personally think,” Stanley said, “that it’s real important for
us to do that before CMS starts saying, ‘Wait a minute, what’s the
difference in these? Because the price differential is meaningful,
so how do we know it makes a difference?’ I think we need to be
stepping up and addressing that prior to it being a concern.

“When you’re already being attacked is not the best time to
come up with your best strategy. You’re never going to be very
successful when you’re already behind.”