CMS Considers Changes To Wheelchair Coverage Policy

Washington

This year, HME industry advocates and the Centers for Medicare and Medicaid Services (CMS) have volleyed back and forth in a K0011 coverage debate that may end with vigilant payment oversight, pricing changes or even changes to national coverage policy for wheelchairs.

Since a DMERC clarification of power wheelchair policy was issued in December, industry stakeholders have spoken out against CMS' strict interpretation of policy language, voicing concerns regarding beneficiary access to medically necessary power equipment and provider payments. Although CMS retracted the clarification in mid-March, some advocates say access questions remain.

At a March 31 Open Door session on the issue, CMS officials said the agency cannot give a more specific definition of its policy language. “Being more specific than the national policy, by definition, will take control away from physicians,” said Timothy Hill, director of CMS' Office of Financial Management. “A more precise definition … will make the circle [of those who qualify for a power wheelchair] smaller and smaller.”

In an Associated Press article published last month, Hill said he does not believe that more K0011 claims have been rejected due to the Medicare policy, adding that “much of what we have seen in the increase in the last few years is a direct result of consumer marketing in the industry, which creates the appearance the benefit is broader than it is.” According to CMS, the years from 1999 to 2003 saw a 300 percent increase in Medicare power wheelchair payments, while overall Medicare spending increased only 11 percent during the same period.

In mid-April, the debate took a twist when the agency announced it is considering making changes to the wheelchair national coverage policy itself. According to Kimberly Brandt, acting director of CMS' Program Integrity Group, “[The national policy] is something that has been widely debated.

Because it dates back to 1985, it's something that may need to be revisited. Our consideration of that will also allow for changes of the local coverage policy.” The CMS official made the comments at an Open Door Forum the agency held April 14 for the disabled community.