PMD Policy Puzzle

Events have been unfolding in the power mobility arena at lightning speed.

At press time, the Senate had approved an amendment to the Labor-HHS Appropriations bill that would delay CMS’ interim final rule on face-to-face exams and new documentation rules. Previous to that, CMS announced the retraction of its second HCPCS code set for power mobility devices, issued Sept. 14, and said that it would start anew. In addition, CMS has announced changes to the Medicare national and regional coverage policies.

If you are confused, you are not alone.

It is primarily because these changes have been issued in a piecemeal fashion, and different policies have different effective dates. In addition, when CMS retracts one policy, it impacts another. All of this results in confusion among prescribing physicians, consumers, suppliers, manufacturers and other stakeholders regarding the fundamental issue: What does Medicare require for a beneficiary to receive a power wheelchair?

Following is a status update on the various PMD issues — at least for now.

• Documentation Issues: Through its “face-to-face exam” interim final rule issued Aug. 26, Medicare completely changed both the criteria for physicians to determine medical need for a PMD, how physicians are to document that need and how suppliers are to review and maintain the documentation. CMS is eliminating the “certificate of medical need” and instead is requiring physicians to provide suppliers with copies of medical records that are to contain information related to medical need. At the same time, CMS had not conducted any real physician education about these changes before the Oct. 25 effective date for the new documentation requirements. Additionally, the billing and claims payment software required to implement the payment of claims will not, according to Medicare, be in place and operational until April of 2006. At press time, we expected this regulation to be rescinded through an amendment to the Labor-HHS Appropriations bill.
• Delay of IFR: The Appropriations amendment would require CMS to publish a proposed rule Jan. 1, 2006, followed by a comment period and publication of a final rule, delaying the effective date for the face-to-face exam and new documentation rules for about six months.
• New Codes for PMDs: In February, CMS issued a set of 49 new codes for PMDs, including new testing requirements, that were to replace the current four codes. Manufacturers were required to test their products and submit applications for the new codes by Sept. 1. On Sept. 14, CMS announced a whole different set of 63 codes to replace the 49 codes and issued new and different testing requirements for the 63 codes. CMS stated that manufacturers who met the Sept. 1 deadline would not have to reapply, and manufacturers who did not meet the Sept. 1 deadline would have until Nov. 15 to submit applications for the new codes with new testing requirements. On Oct. 14, CMS announced it is retracting the code sets for PMDs and will instead establish a more formal process, involving stakeholders, to develop a new (third) set of HCPCS codes for PMDs. We do not know how long this process will take or when new HCPCS codes will be effective, but sometime before the end of 2006 is a likely bet.
• New Coverage Criteria: On May 5, CMS issued new national coverage criteria, effective that day. On Sept. 14, the regional Medicare carriers issued draft regional policies designed to provide information for prescribing physicians and suppliers to understand the new national coverage criteria in conjunction with the new codes.

Under these draft local policies, Medicare will pay for a wheelchair that is functional only in the beneficiary’s home — not outside their homes — truly imprisoning beneficiaries in their homes. However, with CMS’ retraction of the code set for PMDs, these policies will have to be reissued once CMS develops a new set of HCPCS codes.

Undoubtedly, Medicare PMD policies related to coding, coverage, documentation and payment will continue to change over the next 12 months. Be vigilant in making sure you are on top of these changes, and participate and comment at every opportunity.

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].