Many Rivers to Cross

The Centers for Medicare and Medicaid Services’ retraction of the DMERCs’ December Web bulletins on restrictive Medicare coverage for motorized wheelchairs and power-operated vehicles (POVs) was a great victory for the entire power wheelchair community, consumers and the HME industry. It is, however, only the first milestone that the industry, in partnership with consumers, needs to attain.

Our overall objective related to powered and manual mobility is to ensure that consumers with real medical need continue to have access to mobility devices, enabling them to engage in activities of daily life within their homes.

Achieving the following five goals, in conjunction with the consumers we serve, should be an industry priority at the national level.

1. Clarify Documentation Requirements — In addition to the coverage restriction contained in the December 2003 DMERC bulletins, a provision stated that the supplier must provide specific paperwork that documents medical necessity for motorized wheelchairs and POVs. CMS and the DMERCs need to provide appropriate clarification and detail regarding what information will substantiate medical necessity. Importantly, CMS must develop these clarifications based upon realistic expectations of the referring physician. The DMERCs have had an unrealistic expectation that the prescribing physician is intimately knowledgeable about the detailed Medicare coverage requirements and will reflect those same details in the progress notes when prescribing a motorized wheelchair. CMS and the DMERCs must understand that it is the professional responsibility of various licensed and certified therapists to document this detailed analysis of a consumer’s condition.
2. Marketing Guidance — We must recommend responsible policy changes that will address the government’s perceptions of the power wheelchair industry. Like it or not, the government is concerned about certain marketing tactics directed at consumers. CMS should develop detailed guidelines defining appropriate marketing statements and tactics, all within the bounds of current law.
3. More Rigorous Standards — CMS, in conjunction with industry representatives, should develop more rigorous business and quality standards before a provider can receive a Medicare supplier number. As CMS currently is developing additional supplier standards for oxygen providers, standards for providers of powered mobility products also should be applicable.
4. Break Up the K0011 Code — The industry submitted detailed recommendations last year to “break up” the K0011 code into six separate codes as part of CMS’ annual coding update. This coding recommendation included specific clinical criteria for each code. CMS rejected the recommendation in its entirety and provided no explanation for its rejection. The recommended coding would provide the government better information about what products it is paying for, allowing it to pay at a level in line with the product provided. The recommended coding also would provide clinical criteria as a basis for coverage policy to clarify appropriately the specific conditions under which Medicare would pay for a power wheelchair.
5. Appropriate Clarification of Medicare Coverage — CMS needs to issue any changes to Medicare coverage policy based on current clinical and medical information. CMS should seek the input of clinicians, such as physicians and therapists; affected consumers, such as organizations representing seniors and persons with disabilities; and the industry, such as providers and manufacturers.

A specialist in health care legislation, regulations and government relations, Cara C. Bachenheimer is vice president, government relations, for Invacare Corp., Elyria, Ohio. Bachenheimer previously worked at the law firm of Epstein, Becker & Green in Washington, D.C., and at the American Association for Homecare and the Health Industry Distributors Association. You can reach her by phone at 440/329-6226 or by e-mail at [email protected].