CMS Releases New Mobility Coverage Policy

BALTIMORE–CMS’ national coverage determination for mobility
equipment, announced late last Thursday, eliminates the requirement
that Medicare beneficiaries be bed- or chair-confined and instead
adopts function-based criteria for determining medical
necessity.

Medicare’s new coverage policy, effective immediately, hinges on
how well a beneficiary can perform activities of daily living such
as toileting, grooming and eating. It takes clinicians through a
“stepped” process to determine which mobility-assist
device–encompassing a range of equipment from canes and walkers to
scooters and power wheelchairs–is medically necessary.

“This coverage policy ensures that a beneficiary’s functional
status and individual circumstances are considered so that the most
appropriate technology for each beneficiary’s personal needs is
covered,” said Barry Straube, CMS’ acting chief medical officer and
acting director of the office of clinical standards and quality.
“It is also consistent with the documentation of the functional
needs of the patient that should be in medical records for our
beneficiaries.”

The policy continues to limit wheelchair coverage to
beneficiaries who need the equipment primarily in the home–a
sticking point for HME industry stakeholders. But according to the
CMS decision memorandum, the in-the-home rule comes from the
Medicare statute, so “an NCD would not be the appropriate mechanism
to change that [rule].”

The coverage decision is part of Medicare’s larger three-pronged
overhaul of its mobility benefit, begun in 2004 and since dubbed
the Modern Mobility Initiative, which focuses on coverage, payment
and supplier quality standards. In February, the agency introduced
49 new billing codes for power chairs and scooters that will take
effect Jan. 1, 2006. According to a tentative schedule released
earlier this year, CMS has also said it expects to issue new
quality standards for suppliers by this summer.

But some pieces of Medicare’s new mobility reimbursement puzzle
are still missing. Industry insiders had expected the new coverage
policy to be released with several other elements of the
initiative, including a face-to-face physician exam requirement and
a new wheelchair Certificate of Medical Necessity.

“This was supposed to come out as a coordinated package that
would take care of all of the issues,” an agency spokesperson told
HomeCare Monday. However, the NCD was released separately
because it had a deadline dictated by the Medicare Modernization
Act. The spokesperson added that “it is a very high priority to get
the rest of the coordinated package out.”

The government also has yet to release documentation guidance
for providers who must show that beneficiaries meet medical
necessity requirements for mobility equipment. According to the
agency’s decision memo, “While CMS does require adequate
documentation to establish that coverage conditions are met, the
complexity of the issues indicate that this is best addressed in an
initiative separate from the NCD.”

A press release from the agency said CMS plans to issue
additional guidance “in the near future to help physicians and
treating practitioners better understand the new coverage criteria
and CMS’ expectations about proper documentation in the medical
record. Because the new functional criteria more explicitly refer
to standard clinical evaluative methods, CMS expects that the
medical documentation generated during the patient evaluation will
more accurately be reflected in the beneficiary’s medical record.
It is CMS’ intent that this will make the power mobility device
coverage more straightforward.”

“During the course of reviewing Medicare’s policies for power
mobility equipment, CMS came to the conclusion that there are more
accurate tools to root out fraud and abuse,” said Kimberly Brandt,
director of CMS’ Program Integrity Group. “The combination of the
new NCD and the planned enhanced educational outreach by Medicare
to physicians and treating practitioners, as well as to suppliers,
will eliminate most honest billing errors. More accurate claim
submission will allow CMS to better analyze claims data and focus
claims review to target abusive billers.”

In the meantime, the DMERC medical directors are working on a
transition article to be posted on the DMERC Web sites. “In the
transition article, you’ll see [how] the existing CMN will be used
… in line with the new national coverage determination,” said Dr.
Robert Hoover, medical director for the Region D DMERC. “All those
details are still being worked out aggressively.”

Although a new wheelchair CMN is still under consideration, the
transition article will refer only to the wheelchair CMN currently
in use, he said, adding that he is hopeful the interim guidance
will be posted “shortly.”

On Friday, industry reaction to the mobility NCD was mixed. Some
praised the elimination of “bed- or chair-confined” language but
expressed concern about the lack of documentation guidance. Others
said they were disappointed that the policy does not treat mobility
itself as an activity of daily living.

• “We’re very excited,” said Dan Meuser, president of Pride
  Mobility, Exeter, Pa. “It is indeed night and day from the previous
  … archaic ‘bed- or chair-confined’ policy. It’s almost like the
  Wicked Witch is dead. There are concerns with documentation clarity
  that still exist. However, we do expect the DMERCs to understand
  there is a new, clearer coverage policy; therefore, new, clearer
  documentation requirements should be reflective of this new
  policy.”
• “We are pleased at what we saw,” said Eric Sokol of the
  Washington, D.C.-based Power Mobility Coalition. “We are
  disappointed that CMS did not provide [guidance] for current and
  pending claims. This NCD is only for times moving forward.
  Providers are still in the dark,” Sokol said, regarding what
  documents prove medical necessity for a wheelchair. “It is our hope
  a new [wheelchair] CMN will ensure suppliers have more than a
  reasonable explanation of what documents meet eligibility
  criteria.”
• Laura Cohen, a clinical research scientist at the Shepherd
  Center in Atlanta, said that though the policy does treat
  activities like grooming and bathing as activities of daily living,
  CMS does not consider mobility itself as such an activity. That,
  she said, could create problems for clinicians. “[CMS] says that by
  itself, [mobility] does not serve a medical purpose. It’s ironic
  that a wheelchair isn’t being acknowledged as necessary for
  [someone to attain] mobility.” Cohen is also co-coordinator of the
  Clinician Task Force of the Coalition to Modernize Medical Coverage
  of Mobility.
• According to Barbara Crane, CTF co-coordinator and professor at
  Hartford University, “Environmental considerations are essential in
  order to match an individual to the appropriate technology
  solution,” she said. “The new NCD ties our hands and confines
  clinical practice to the confines of the home.”
• A statement from the Restore Access to Mobility Partnership–a
  coalition that includes the American Association for Homecare,
  Invacare Corp., the MED Group, Mobility Products Unlimited, Pride
  Mobility and Sunrise Medical–echoed the clinicians’ concerns.
  While the new NCD is “a step in the right direction,” the statement
  read, “Clinicians, as well as advocates for people with
  disabilities, have repeatedly advised CMS that ‘mobility for
  mobility’s sake’ should be treated as an activity of daily living.
  Giving a Medicare beneficiary increased mobility with a power
  wheelchair can be just as significant for an individual as using
  the equipment to improve the ability to get to the bathroom, eat,
  dress, groom or bathe. CMS also chose not to change the requirement
  that power mobility equipment be restricted to increasing a
  Medicare beneficiary’s ability to perform activities in their home.
  This provision contrasts sharply with clinical practices …

  “Lastly,” the statement continued, “these new coverage
  guidelines make it imperative that a clear and comprehensive
  documentation process be quickly established so that all of the
  stakeholders–beneficiaries, doctors, clinicians and
  providers–have a full understanding of what medical documentation
  will be definitive for claims to be approved.”

• “Our next steps? Documentation, documentation, documentation,”
  said Cara Bachenheimer, vice president of government relations for
  Elyria, Ohio-based Invacare. “The DMERC medical directors are
  responsible for Local Medical Review Policies based on this
  national coverage determination, so there’s an opportunity for the
  DMERCs to provide significantly more clarity than what now exists
  in the national policy.”

The NCD is posted on CMS’ Web site, available by clicking
here.