Finally!

Last month, CMS announced two important national Medicare policy developments related to mobility devices including power wheelchairs, scooters/POVs and manual wheelchairs. CMS is proposing to use a series of functional criteria as the national coverage policy for wheelchairs, and has announced a set of 49 new HCPCS codes for power wheelchairs and scooters, or power-operated vehicles (POVs).

On Feb. 3, CMS released proposed coverage criteria for mobility assistance equipment on its Web site. The agency stated that it plans to issue the final National Coverage Determination (NCD) in late March, although it is unclear how quickly CMS will implement the new national policy.

In December, CMS announced its initiation of the NCD process for mobility equipment, including power wheelchairs, POVs and manual wheelchairs. After a 30-day comment period that ended Jan. 14, CMS posted the draft NCD, which proposes to delete the “bed or chair confined” criterion currently used to determine if a wheelchair is reasonable and necessary. Instead, beneficiary eligibility for coverage of mobility equipment would be based upon an assessment of a person’s ability to functionally ambulate.

CMS is proposing to use the following sequential clinical criteria to “provide clinical guidance for the prescription” of equipment. The document does not say, however, whether it is the prescribing physician, another clinician such as a physical or occupational therapist or other individual who responds to these questions for a beneficiary.

1. Does the beneficiary have a mobility limitation causing an inability to perform one or more mobility-related activities of daily living in the home?
2. Are there other conditions that limit the beneficiary’s ability to perform mobility-related activities of daily living at home?
3. If these other limitations exist, can they be ameliorated or compensated sufficiently such that the additional provision of mobility equipment will be reasonably expected to materially improve the beneficiary’s ability to perform mobility-related activities of daily living in the home?
4. Does the beneficiary demonstrate the capability and the willingness to consistently operate the device safely?
5. Can the functional mobility deficit be sufficiently resolved by the prescription of a cane or walker?
6. Does the beneficiary’s typical environment support the use of wheelchairs or scooters/POVs?
7. Does the beneficiary have sufficient upper extremity function to propel a manual wheelchair in the home through the course of the performance of mobility-related activities of daily living during a typical day?
8. Does the beneficiary have sufficient strength and postural stability to operate a power-operated vehicle?
9. Are the additional features provided by a power wheelchair needed to allow the beneficiary to perform one or more mobility-related activities of daily living?

Importantly, CMS did request public comments on what would constitute adequate documentation to substantiate medical need, as well as on the proposed criteria above. The agency held an Open Door Forum in late February to allow clinicians, suppliers, beneficiaries and other interested parties to provide input about the proposed NCD, and set the comment period on the draft coverage to conclude on March 7. But as requested by many consumer/disability, clinician and industry groups, CMS did not address the current Medicare restriction on coverage for DME within the home.

Also last month, CMS issued 49 new HCPCS codes for power wheelchairs and scooters that will go into effect in 2006. The new codes incorporate testing standards, such as weight capacity, fatigue testing, speed and range. Fees for the new codes will be calculated late in 2005, after manufacturers’ products have been assigned to specific codes.

To view CMS’ proposed national coverage decision, visit www.cms.gov and click “coverage” on the left menu bar. Click “tracking sheets,” then select “mobility assistive equipment.” To view the new mobility codes, visit: www.cms.hhs.gov/suppliers/dmepos.

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].