PSCs Delay Power Mobility Codes, LCD

Baltimore

After much protest from power mobility manufacturers, providers, consumer groups and lawmakers, the DME Program Safeguard Contractors announced last month that they would delay implementation of the new power mobility codes and Local Coverage Determination until Nov. 15.

The announcement came at the same time the PSCs released a modified LCD. The document eliminates the “least costly alternative” determination that would have resulted in automatic downcoding to a Group I power wheelchair for patients not meeting coverage for a Group II or higher chair.

Stakeholders had argued that such downcoding would restrict beneficiaries to inexpensive, low-powered models that could prevent some from getting the equipment appropriate to meet their needs. CMS said the revised policy “allows for greater flexibility to ensure beneficiaries are in the right chairs for their medical condition.”

“The LCD revisions went a long way to address the industry’s concerns,” said Seth Johnson, vice president, government affairs, for Exeter, Pa.-based Pride Mobility and chairman of AAHomecare’s Rehab Council, who added that he was pleased with the extension of the transition period.

The 64 new PMD codes, pricing and LCD originally were scheduled to take effect Oct. 1, which many industry stakeholders and some members of Congress argued was too soon.

In recent letters to CMS and HHS, Sens. Arlen Specter and Rick Santorum and Rep. Don Sherwood, all Pennsylvania Republicans, asked for a delay. Also, 12 organizations representing people with disabilities signed an advertisement in Capitol Hill newspaper Roll Call urging Congress and HHS to delay implementation of the LCD.

According to CMS, fee schedules for the new codes “should be available in the near future.”

Rita Hostak, vice president of government relations for Longmont, Colo.-based Sunrise Medical and president of the National Coalition for Rehab and Assistive Technology, also said the implementation delay and elimination of automatic downcoding were positive moves, but added she has other issues with the LCD.

“We still have significant concerns [about] the language regarding an individual’s ability to perform an independent stand-pivot transfer. This coverage criterion will deny individuals with disabilities access to equipment that will be functional and meet their needs,” said Hostak, noting that “we must make every effort to ensure that the adverse restrictions in this policy are eliminated.”

Many rehab stakeholders are concerned that CMS’ interpretation could include people who face a severe struggle to transfer themselves without assistance.

“When you have claims reviewers looking at these claims, it’s going to come back to what their definition is of ‘independently,’” Johnson said. “The rehab community would really like some further communication as to what an ‘independent transfer’ is.”

Don Clayback, senior vice president of networks for The Med Group, Lubbock, Texas, called the revised LCD “a step in the right direction, but there are still some significant issues for customers with more complex disabilities.”

In addition to the stand-pivot transfer issue, he said providers need further clarification on coverage of complex equipment, specifically Group III or higher.

“Providers need the assurance that they’re going to get paid so that access is not a problem,” he said, recommending that officials either modify the policy or expand the Advance Determination of Medicare Coverage so providers know up front whether they will be reimbursed for a claim.