In a Nov. 30 discussion with officials from the Centers for Medicare & Medicaid Services (CMS), representatives from the Complex Rehab Technology (CRT) industry made their case for the complexity of power seat elevation and the CRT clients who use it.
The forum was the second biannual HCPCS Coding Cycle public meeting, held by CMS to discuss its recommendations for coding and funding for power seat elevation on power wheelchairs for Medicare beneficiaries.
CMS Provides Coding Recommendations
CMS released its coding recommendations in early November, following its May decision to begin Medicare coverage for seat elevation.
In that May decision, CMS surprised industry stakeholders by announcing it would cover seat elevation on Group 2 consumer power chairs as well as Group 3 Complex Rehab power chairs. The industry had asked for coverage consideration only for Complex Rehab power chairs.
Then in early November, CMS released preliminary coding information that gave the home medical equipment (HME) and the CRT industries insight into CMS’s plans.
CMS recommended eliminating the current E2300 (Wheelchair accessory, power seat elevation system, any type) HCPCS code and adding two new codes.
The first code would be defined as “Complex rehabilitative power wheelchair accessory, power seat elevation system, any type.” The second code would be “Power wheelchair accessory, power seat elevation system, any type.”
The second code, CMS explained, would apply to seat elevation on non-CRT power chairs. The agency said, “The establishment of this new accessory code may obviate the need for existing non-complex rehabilitative Group 2 codes that describe an integrated seat elevation system and a Group 2 power wheelchair base.”
Therefore, CMS also recommended eliminating the K0830 (Power wheelchair, Group 2 standard, seat elevator, sling/solid seat/back, patient weight capacity up to and including 300 lbs.) and K0831 (Power wheelchair, Group 2 standard, seat elevator, captain’s chair, patient weight capacity up to and including 300 lbs.) codes.
But by recommending a single CRT seat elevation code, CMS also indicated it believes one code can appropriately accommodate all complex seat elevation users.
The CRT Industry Responds
Per the coding meeting’s format, Julie Piriano, PT, ATP/SMS, VP, Clinical Education, Rehab Industry Affairs and Compliance Officer, Quantum Rehab, was the CRT industry’s primary presenter and was given 15 minutes to speak. Bill Ammer (Ammer Consulting), Brad Peterson (VP of U.S. Sales, Amylior) and Peter Thomas (ITEM Coalition/Powers Pyles Sutter & Verville) followed Piriano and were given five minutes each to speak.
Piriano urged CMS to recognize seat elevation as a system in and of itself, not as an add-on to another type of seating system, such as tilt.
She also recommended that CMS designate minimum performance characteristics for CRT seat elevation, which Piriano defined as at least 10 inches of elevation; the capability for the seat to elevate or lower while the power wheelchair is in motion; the ability of a power wheelchair to move across a horizontal surface while seat elevation is in use; and the ability of the seat elevation system to work with tilt and recline.
As Piriano spoke, she showed a PowerPoint slide of NCART’s position on the preliminary CMS decision. That position included a request that CMS “adopt the code description proposed in the NCART code application and recognize CRT PSE [power seat elevation] as a stand-alone system, the same as power tilt and/or power recline, and not merely as an add-on component.”
CMS Questions the Need for a Heavy-Duty Distinction
A major talking point for CRT presenters — and one repeatedly questioned later in the meeting by CMS representatives — was the need for a separate HCPCS code for heavy-duty seat elevation systems.
In its position statement, NCART asked CMS to “Reconsider the need for a separate HCPCS Level II code for heavy-duty CRT PSE, and consider the healthcare disparity and access to care concerns.”
Peterson — an industry veteran who has specialized in powered seating — said he believes seat elevation is a system rather than an add-on element, such as elevating legrests. Peterson asked CMS for a separate code for heavy-duty seat elevation, noting that without that code, access for heavier consumers will be compromised.
Peterson added that the costs of manufacturing standard and heavy-duty power wheelchairs are not the same. Engineering a heavy-duty power wheelchair is complicated, for example, by the need to accommodate large amounts of weight that are carried asymmetrically by many power chair riders.
Thomas, who followed Peterson in the presentation order, agreed that a heavy-duty code is needed, and said safety would be compromised without that separate code. Thomas said he is “very concerned about that. People will potentially be at risk.”
He added that power chair users who don’t need heavy-duty chairs with higher weight capacities wouldn’t want the added weight of heavy-duty components.
Asked about potential funding for heavy-duty seat elevation systems, Piriano said the industry would need to investigate appropriate reimbursements, given the different weight capacities of heavy-duty products. But Piriano pointed out that CMS already offers heavy-duty reimbursements for other products.
In answer to a CMS representative’s comment that it “would be helpful” to have data on the costs of heavy-duty power wheelchair engineering and fabrication vs. the costs of power wheelchairs for standard weights, Piriano repeated Peterson’s assertion that heavy-duty power chair users often carry their weight differently from user to user. Some riders, Piriano explained, carry most of their weight above the waist, while others carry most of their weight below the waist.
Seat Elevation Funding Questions
While CMS had proposed gap-filling to determine seat elevation funding, Piriano said the seat elevation fee schedule should reflect the complexity of the technology, and added that CMS’s proposed reimbursement rate is too low.
In support of the CRT industry’s contention that seat elevation is a highly complex system, Ammer — who conducts wheelchair stability tests as a consultant — said it’s a challenge to keep a power chair base stable while its seating is elevated. Ammer also discussed dynamic stability and how a power chair’s center of gravity changes as its seating rises and descends.
Peterson noted that seat elevation components are identical to components used in power tilt and power tilt-recline systems, and that therefore, seat elevation should also be considered a seating system, rather than an add-on component.
Thomas said current CMS payment suggestions would cause access issues, adding, “We have significant concerns with the gap-filling process.” Instead, Thomas suggested cross-walking seat elevation to existing technologies — namely, tilt and recline.
And Piriano added that manufacturing costs of achieving stability on a heavy-duty power chair base exceed the costs of creating comparable stability on a standard power wheelchair base. She again cited the fact that consumers with higher body weights carry their weight in different parts of their bodies and not necessarily symmetrically.
Peterson noted that asymmetrical body weights stress power chair actuators and cause instability. When a CMS representative expressed concern over the safety of higher body-weight consumers driving their power chairs while elevated, Piriano said that’s why standards, testing, and code verification are crucial. Those standards, Piriano explained, prevent products that don’t pass from coming to market.
Asked if the industry would also request new seat elevation repair codes, Piriano said no — that the industry anticipates a repair process similar to the process for tilt and recline. She explained that tilt-and-recline components or the entire tilt-and-recline system can be replaced, and seat elevation is a system whose repairs could be addressed in a similar way.
CMS asked for information on how a user’s weight can shift — thus changing center of gravity — as a seating system moves. Piriano said the CRT team working on this seat elevation issue has asked power chair manufacturers to provide that information as soon as possible.
The Consumer Power Question
NCART and the CRT industry recommended that CMS hold off on eliminating the K0830 and K0831 codes.
During the Q&A session, Robert Hoover, M.D., MPH, FACP, Chief Medical Officer at CGS Administrators, said he didn’t understand the objection to eliminating those codes. Piriano replied that the industry needs to conduct additional research into seat elevation usage on non-CRT power chairs.
Because that work hasn’t yet been done, Piriano explained, the industry doesn’t want unintended consequences to arise from the premature elimination of the codes.
Thomas added that as the original ITEM Coalition coverage request didn’t include seat elevation on Group 2 power chairs, the industry would prefer to keep the codes active while additional research is being done.
He suggested the future of the two codes could be reconsidered in the spring.
Piriano was also asked if she knew of any studies that focused on seat elevation for scooters. She replied that she didn’t know of any studies, but hadn’t looked for any.
NCART Lists Its Requests
NCART’s requests for CMS in light of the agency’s coding recommendations included:
— adopting the seat elevation code description in the NCART code application;
— recognizing CRT seat elevation as a stand-alone system akin to power tilt and/or power recline;
— requiring that CRT power seat elevation systems possess the minimum performance characteristics outlined in the NCART code application;
— reconsidering a separate code for heavy-duty power seat elevation;
— reconsidering the assertion that power tilt is not comparable to power seat elevation, while considering the ANSI/RESNA testing specifications for dynamic stability;
— reconsidering power tilt “as a comparable DMEPOS item for which a fee schedule amount already exists when establishing a fee schedule for CRT PSE”;
— and pausing the addition of a new code for standard seat elevation for now, while adding this discussion to a future coding meeting when the industry has more information.
CMS said it expects to announce a final decision in February 2024, with that decision going into effect April 1, 2024.
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