Mobility Management

The Adjustable Cushion Code Quandary

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small and large red apples

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Inclusion is an important goal in the complex rehab technology (CRT) industry. Innovative seating and wheeled mobility recommended, built and fitted by expert clinicians and providers can support new levels of independence and participation for consumers.

But inclusion can hinder access to CRT when it’s applied too widely to Healthcare Common Procedure Coding System (HCPCS) codes, those letter-number combinations intended, according to the Centers for Medicare & Medicaid Services (CMS), “primarily to identify products, supplies, and services not included in the CPT-4 codes, such as ambulance services and durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) when used outside a physician’s office.”

Many CRT experts believe adjustable wheelchair seat cushion codes are too inclusive, with definitions so broad that large numbers of products apply, even though the products demonstrate varying levels of functionality and don’t allow an “apples to apples” comparison. Such widely inclusive codes can impact many facets of CRT, from reimbursement to product innovation, clinical outcomes and consumer access.

What’s the Goal of a HCPCS Code?

The four adjustable cushion codes are E2622 (skin protection, adjustable, width less than 22″, any depth); E2623 (skin protection, adjustable, width 22″ or greater, any depth); E2624 (skin protection and positioning, adjustable, width less than 22″, any depth); and E2625 (skin protection and positioning, adjustable, width 22″ or greater, any depth).

Rita Stanley is VP of Government Relations for Sunrise Medical. She is one of the industry’s most highly regarded and experienced experts on HCPCS coding, coverage policy and funding, and she has a long history of addressing codes that the CRT industry believes are too broad. That includes the adjustable seat cushion codes.

When it comes to widely inclusive codes, Stanley thinks the problem starts at a very elementary level, with varying perceptions of why HCPCS codes exist and what they’re supposed to accomplish.

“It starts at the assumption of ‘What is a HCPCS code and why is it used?’” Stanley said. “I believe that [CMS] thinks HCPCS codes, due to regulation or legislation, cannot consider how coding impacts coverage and payment when CMS is assessing code applications. In their minds — and they’ve said this any number of times to me — HCPCS codes are purely a billing mechanism.”

Granted, HCPCS codes are used on CRT insurance claims. But that’s just one way they’re used.

“The reality is [the codes] are also how coverage is developed,” Stanley said. “It’s how payment is developed, and if you don’t delineate product properly [within the codes], you have no way of tracking utilization.”

Comparing Like Products

Tracking utilization — knowing which CRT products are being provided and used — is critical to measuring patient outcomes. But when a HCPCS code is so broad that it includes a number of products with varying abilities and functions, it’s impossible to determine which, if any, of the products are delivering desirable results.

Right now, Stanley pointed out, payors “can tell you how many times that code was billed, but they cannot tell you anything about what was provided within that code. You have no way whatsoever of tracking outcomes for patients based on the range of technology that’s within a single code, and it creates enormous burdens to do research that would demonstrate the efficacy of certain products for various patient populations. You can’t test one code to the next. You would literally have to test every single product against every [other] product inside the same HCPCS code. That’s unsustainable, and nobody could afford it in our industry because the industry is just too small.”

The Start of Adjustable Cushion Codes

The adjustable seat cushion codes in use today were born from the best of intentions. In the early 2000s, Stanley said, CMS set out to create a set of seat cushion codes that would work better than the single code being used at that time.

“Dr. [Kenneth] Nelson and Dr. [Doran] Edwards had both put in a considerable amount of time looking at the products and thinking about how to verify that the products were even effective, because there was no way to test them or measure them, or no requirement for testing,” Stanley said. “They had worked closely with RESNA on the standards regarding cushion testing, and part of the problem was the limited number and types of tests that were established for cushions. (See

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“The problem with that theory is suppliers that are providing the standard product are not typically the same suppliers who are doing the majority of the CRT. So the supplier who does complex rehab all day long never sells enough of the product that he makes margin on to make up for the products he loses money on. So he’s losing money almost every single time.”

Many Stakeholders, One Goal

If there’s a bright spot in the ongoing challenge of adjustable seat cushion codes, it’s this: Aligning the HCPCS codes with function and outcomes would benefit all involved parties.

“All stakeholders win in a scenario where HCPCS codes are established based on technological and functional differences and their benefits to consumers, and then payment and coverage are all associated with that properly,” Stanley pointed out. “The payor is paying for what the consumer is receiving. Consumers are getting what they need. And you’ve even promoted the economic side of it: Manufacturers are going to develop innovative products that meet unmet medical needs.”

For that to happen, Stanley believes that a product’s functions and features need to be part of the code that’s being created.

“The model needs to change, with technological differences and the functionality and features [becoming] the basis for coding,” she said. “For headrests alone, you could easily have five or six different codes that would represent the array of headrest technology. You could go through each of the HCPCS codes and clearly identify features and functions: What are those technological differences that are relevant, and why are they relevant, and who are they relevant for?

“If that were the basis of the HCPCS code set, you would see a very different outcome for every single stakeholder, including payors. Then if they decide to competitively bid the standard technology, at least everybody is bidding on the same features and functions. It may not be the exact same cushion, but at least the minimal standards are consistent, and you don’t have a whole array of product that exceeds the minimum requirements, but nobody can obtain it because of the cost.”

In that model, products within a code would all have comparable features and functions to serve a common patient population. Manufacturers could choose to differentiate their products in other ways, such as by improving aesthetics.

“If I want to add features that make it preferable to a consumer, but aren’t a medical necessity — if I make mine weigh five ounces less, or I paint it some new funky color of pink — that’s something that becomes patient choice and becomes a manufacturer’s prerogative, and we compete in those different ways,” Stanley said. “But when it comes to medical necessity, patients shouldn’t have to pay out of pocket. That should be something covered by their insurer, whoever their insurer is.”

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