Features

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
by Cara C. Bachenheimer, Esq.

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.

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