Big Changes

At the national level, the Centers for Medicare and Medicaid Services (CMS) is making a series of what will be major changes in 2005 to the way that Medicare codes, covers and pays for power wheelchairs. All of these actions have been, at least in large part, taken by CMS in response to the massive power wheelchair fraud in Houston, uncovered by the media in August 2003.

In a perfect world, CMS would implement these coding, coverage and payment changes in logical progression. Unfortunately, due to a variety of reasons, CMS is not necessarily developing these changes in tandem, nor is it rolling them out in logical order.

Following are the changes you can expect:

• New Face-to-Face Examination Requirement By the time you read this, CMS will likely have issued an interim final regulation implementing the 2003 Medicare Modernization Act’s requirement that all beneficiaries have a “face-to-face examination” prior to the physician prescribing the power wheelchair. The proposed regulation had a restrictive time frame, requiring the examination to occur within 30 days of the prescription, and also required the physician to maintain all medical necessity information in the patient chart. CMS hopes to implement the final face-to-face examination requirement early this year.
• New CMN CMS has drafted a new certificate of medical necessity (CMN) that will replace the current CMNs for manual wheelchairs, power operated vehicles (POVs) and motorized wheelchairs into one CMN. CMS’ vision is to have the prescribing physician proceed through a hierarchy of questions — from manual wheelchairs, to POVs, to power wheelchairs — ensuring that the consumer receives the least costly device.
• New Coverage Guidance In June 2003, CMS convened an Interagency Wheelchair Work Group, made up of physicians, physical and occupational therapists and other clinical experts from various federal agencies, to develop a document that would better explain the current brief national coverage criteria for power wheelchairs. At press time, however, CMS had decided to take a draft of the Work Group’s document through the National Coverage Determination (NCD) process. This is a formal process that could result in a new NCD that will replace the current national coverage policy for wheelchairs, both manual and power. CMS expects the process to be completed by Sept. 12, 2005. The Work Group’s proposal recommends that CMS “cease applying its ‘bed or chair confined’ standard and adopt new, functionally based clinical criteria for mobility device prescribing.” The Work Group identifies specific clinical criteria for prescribing a wheelchair.
• New Documentation Guidance Equally important to the coverage criteria is guidance for suppliers regarding the appropriate documentation to substantiate medical need in the event of an audit. CMS is developing such guidance and plans to release it in early 2005.
• New HCPCS Codes CMS and the SADMERC are developing new codes for power wheelchairs and POVs. The approximately 50 new HCPCS codes are a significant improvement in better defining the available technology. CMS plans to implement the new codes in July 2005.
• New DMERC Medical Policies Once the new power wheelchair and POV HCPCS codes are final, the DMERCs must develop medical policies for these new codes. These new medical policies would be effective with the new codes, currently scheduled for July 2005.
• New Payment Amounts for Power Wheelchairs Once the new HCPCS codes are final, manufacturers must conduct testing requirements to determine whether they meet code specifications. They then must submit code verification applications to receive SADMERC coding decisions, which will be used to determine payments for the new codes.

Note: Dates in this article were current as of press time. For more on the wheelchair NCD, see Headline News, page 12.

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].