In December, Medicare DME MAC and Pricing, Data Analysis & Coding contractors made a “correct coding” announcement concerning manual wheelchairs with titanium frames and use of the K0108 “miscellaneous” HCPCS code.

“A recent review of K0108 identified increased billing for items that are characterized by titanium construction or heavy-duty packages constructed with titanium,” the announcement said. “The HCPCS codes for manual wheelchairs (K0001-K0009) were created in 1993 … The Medicare fee schedule amount for these codes was established with the original code and included the cost of titanium-containing manual wheelchairs. Suppliers billing for manual wheelchair bases must not include HCPCS code K0108 in addition to the base wheelchair code when a wheelchair is constructed of titanium or for a ‘heavy duty package’ reflecting titanium construction materials.”

A Frame Is a Frame?

John Goetz, senior director of government affairs for Permobil, said the decision sharply restricts consumers’ access to titanium technology.

“To be very clear, nobody is asking Medicare to pay for this,” Goetz said. “We’re asking for Medicare to allow someone to purchase [the titanium upgrade] if they want to with their hardearned money.”

The CMS argument is that the K0005 ultralightweight wheelchair code and its allowable — created in 1993 — included payment for any type of wheelchair frame that might be used.

“[CMS] basically says that when they created the code and the corresponding fee schedule, they intended any material that [the frame] could be made of,” Goetz said. “So you can’t separately bill for titanium because the code and the allowable are supposed to [already] include those materials. They said when they created it, they anticipated all materials that it could be made out of, and the allowable should [already] cover that material cost.”

Josh Anderson, an ultralightweight wheelchair user and VP of marketing for Permobil, says CMS’s announcement robs consumers of the ability to make their own choices.

“Limiting access to an upgrade is really the problem,” he said. “Even if you could afford it, you can’t get it because of the way things have been worded, that [titanium] just part of the frame.”

Titanium Today, but What’s Next?

Goetz noted that the new policy leaves little room for consumers to obtain that titanium upgrade.

“The only way is if you could get a dealer to take [the claim] completely unassigned,” he said. “Essentially, the end user would put out the entire cost of the wheelchair up front and wait for Medicare to pay them back for whatever the difference is. Not all dealers are willing to take unassigned [claims].”

An even bigger concern: Anderson believes the titanium decision is just the start.

“I think they’re dipping their toes in the water,” he said of CMS. “If they’re looking at titanium as not being a funded option, then what about the heavy-duty (HD) package for chairs? HD chairs typically use a thicker wall tubing, and that thicker wall tubing has more cost to it. HD chairs are beefier — nuts and bolts, caster housings, even the types of casters, something that’s going to support more weight and heavier use. But the way that Medicare is interpreting this is that those are changes to the frame — and the frame should be covered in any configuration. What happens with a reinforced frame for a power add-on system? This can propagate into something much larger very quickly.”

Goetz agreed. “The longer this goes on and the longer the industry allows it to happen, it’s going to give the message to CMS and contractors that this is something the industry is willing to accept. And therefore, they’re going to try to move into other areas and try to restrict that access, too.”

A Funding Domino Effect

Goetz said that other payors are likely to follow Medicare’s lead.

“While this is an immediate effect on those who are Medicare eligible, it is also going to trickle down to other payors,” he noted. “Medicaid follows Medicare policy, and when Medicaid updates its policy, it’s going to start restricting access to [titanium], but also private insurers who follow Medicare coverage policies are going to do the same thing.”

Will Medicare be content to stop at titanium, or will the agency push to further reduce payments for ultralight chairs?

“It’s going to snowball,” Anderson said. “You can get an ultralightweight chair in aluminum. You might not be able to get it as light as with a titanium [chair], it might not have the same level of durability or comfort, but okay, you can get it in aluminum. Maybe then CMS thinks, ‘Chromoly chairs were less expensive than aluminum, so we’re not going to fund aluminum as a material anymore. And the HD package, the power-assist package, those are changes to the frame, and all frames are covered as one reimbursement.’ All that goes away.

“Now you have somebody who really needs that HD chair, and they can’t get it. They’re put into a regular chair that they’re going to break in three months. Somebody has a power add-on system and they can’t put it on their new chair. Where does it stop?”

Goetz said Permobil submitted a Freedom of Information Act (FOIA) request, seeking documentation to determine whether titanium was actually taken into consideration when manual wheelchair codes and allowables were established in 1993, a time when titanium wasn’t widely available in the industry.

“Our initial FOIA came back with zero results,” Goetz said. “They said there were no documents [proving there were discussions about titanium].”

Permobil has submitted a second FOIA request for a much wider range of correspondence to ask whether titanium was part of the 1993 funding conversation. “We want to be airtight in saying, ‘Your internal documents show that this was not the case,” Goetz said. “We’ve not gotten that second FOIA back yet. We’re saying, ‘You say [titanium] was part of it; prove it.’”

Anderson pointed out that ironically, the consumers being denied upgrade access “are the ones who have really done their research. They understand the benefits, they’re spending 12 to 14 hours in the chair, so it’s reducing their fatigue. This is the kind of person that I think the system really wants to help. They are contributing to the system because they’re working, more than likely. They want to return to a completely active lifestyle, and we’re making that more difficult for them. We’re not asking for Medicare to pay for a titanium upgrade, just to keep the access available for those individuals that recognize the benefit.”

Permobil is urging consumers to contact Congress (http://hub.permobil.com/advocacy) to personally voice opposition to Medicare’s decision.

Regardless of whether you prefer titanium in your ultralight frames or not, Goetz said the issue now is fairness.

“At this point, it’s about your rights to get what you want to have. If I want to go and purchase something with the money I’ve saved, I should be able to. Why does a Medicare beneficiary not have the same rights?”