By October 2003, every piece of durable medical equipment in the United States must have its own national billing code, according to a massive 1996 medical privacy law.

When in place, the national codes will make everyone's life easier, but the process of creating the codes could be painful, says Rita Hostak, chair of the coding committee for the Alexandria, Va.-based American Association for Homecare's Rehab and Assistive Technology Council, and vice president of government relations for Longmont, Colo.-based Sunrise Medical.

The government is not nearly ready, Hostak explains. “[While officials] realize what has to happen, I don't think anybody realized how huge this was going to be.”

To meet the challenge, AAHomecare's coding committee has been working diligently to help the Baltimore-based Centers for Medicare and Medicaid Services develop new codes for countless mobility products and accessories and to ensure that the new codes are clear, specific and comprehensive.

Against this backdrop, Medicare's four regional claims-processing contractors in December 2001 proposed changes to the existing national codes for wheelchair seating products, and asked the home medical industry for comments on the proposal.

WHY ROCK THE BOAT?

Some might wonder, why now? Why in the midst of all these other coding changes would Medicare's durable medical equipment regional carriers decide to tamper with wheelchair seating codes?

The answer, according to Hostak, is that the DMERCs — and the DMERCs' code-reviewing arm, the statistical analysis DMERC — were tired of processing claims bearing oversimplified codes for a complicated array of products.

“I don't think there's any magic to the timing of the draft policy,” Hostak says. Rather, “any time the DMERCs or the SADMERC believes that a general or vague code descriptor is increasing the risk for a Medicare beneficiary to receive an inappropriate product, the code descriptor will get attention.”

And, the wheelchair seating codes certainly are vague — especially the EO192 code, which describes nearly 100 products from dozens of different companies, Hostak continues. “You would be amazed at how many EO192s are out there.”

Such vagueness leads to problems for everyone involved in the billing process, according to Simon Margolis, a member of the coding committee and vice president of clinical and professional development for the Franklin, Tenn.-based provider National Seating and Mobility.

For example, miscellaneous seating codes, such as KO108 — an umbrella code for all “not otherwise coded” wheelchair accessories — cause big reimbursement headaches for providers who rely on Medicare money to pay bills and stay afloat, Margolis explains. Often, providers billing Medicare under the KO108 code wait as long as five months to receive reimbursement, and, “since the manufacturer wants its money within 40 to 60 days, this is a problem,” he says.

“A miscellaneous code requires someone [at the DMERC] to pull the claim, look at it and check the coding criteria — and that takes up to several months,” according to Debra Harrington, a nurse and former SADMERC product reviewer who now runs her own consulting firm, Harrington Consulting, in Lexington, S.C.

More-specific codes will allow the DMERCs to process claims more quickly, and that is good news for providers, Margolis explains. “We can get paid faster, and that's obviously the most critical issue.”

For manufacturers who currently are developing products based on scanty criteria guidance, the new codes could make a world of difference, Harrington says. “[Medicare] is trying to create a seating-and-positioning medical policy that says in black and white, ‘It's got to do this, and it's got to look like this.’ If they can give us specifics, then we have something to work with, and that's what we need.”

In the past, when the SADMERC altered the criteria for a specific code, manufacturers were left in the dark, Harrington explains.

By publishing this wheelchair seat coding policy, the DMERCs are turning on the light, because “when they make changes to published policies, they publish the changes,” she notes. “They update everything quarterly.”

The new seating codes also will benefit beneficiaries and third-party payers, including HMOs, the experts agree, by ensuring that patients receive only what is medically necessary.

Under the current coding system for wheelchair seating products, providers have financial wiggle room, Harrington explains, and unscrupulous providers take advantage of the leeway. “The inclination is to put the most expensive product under the patient. If you can buy something for $30 and you can make $300 from it, then that's the item you want to put under the patient.”

Specific codes would curb this practice and ultimately would serve honest providers well, by decreasing the incidence of fraud and abuse — and thus diverting government auditors' critical eye, Margolis says.

NAVIGATING THE CHANGES

The 14-page wheelchair seating draft policy “probably is one of the most complex draft policies that I've ever been involved in developing comments for,” Hostak says.

Addressing the policy's many provisions, AAHomecare's coding committee “focused on trying to make sure the codes were right,” she adds. “We made recommendations on ways [the DMERCs] could reword or better define some of the products for which they had developed codes and descriptors.”

Currently, many providers are reluctant to offer a product until the SADMERC has verified in writing that the product falls under a specific code, Hostak continues.

However, obtaining code verification from the SADMERC still will be important for providers, even after the new policy is in place, Harrington cautions.

“Before suppliers purchase a cushion — or any product that requires Medicare review — from a manufacturer, they need to ask for a copy of the [verification] letter from the SADMERC,” and a manufacturer's letter will not suffice, she says. “That's the best way to do it now, and that will be the best way to do it after the policy is published.”

In fact, the draft policy includes a provision that would require manufacturers to submit all wheelchair seat cushions to the SADMERC for code verification before selling the products, Hostak says.

“So, as the policy reads now, I won't be able to sell [a new wheelchair seat] product until 90 days after I'm ready to sell it,” she explains.

Another potential problem for manufacturers is a provision in the draft policy that requires manufacturers to subject all new wheelchair seat cushions to independent tests and to submit the test results to the SADMERC along with every code verification request.

Because AAHomecare primarily is concerned with providers, however, the coding committee did not address this issue in its comments to CMS, Hostak notes. “We left it up to the individual manufacturers to submit their own comments.”

CLEAR SKIES AHEAD

Despite these potential challenges, many manufacturers support the proposed code changes.

“Everyone in the industry knows that this was a long time coming and it needs to be done,” says Betty Fendrick, pressure care product manager for Camp Healthcare in Jackson, Mich. “It's just the pain of going through it” that sometimes makes the process difficult, she adds.

Fendrick and Camp experienced this pain first-hand recently, after submitting a new wheelchair seat cushion to the SADMERC for code verification. Although Camp included positive independent testing results with its verification request, the company did not receive the code it was hoping to receive, Fendrick says.

But, “I think everyone is going through this right now,” she explains. “I believe the decision-making process was based on some of these new codes and criteria that no one has really decided upon.”

Nonetheless, Fendrick looks forward to a time when the criteria for wheelchair seating codes will be clear and accessible, and she says Camp recovered quickly from its coding disappointment. “We've redone the cushion,” she explains, “and we will resubmit it.”

Unfortunately, no one seems to have any idea how long the re-coding process for wheelchair cushions will take. “Our comments were due in January, but I have not heard anything” about where the DMERCs are in the policy-revision process, Hostak says.

“I doubt that anybody could give you a timeline,” Harrington agrees. “The DMERCs have gotten a lot of comments on this policy, and they have to consider everything. It could be a month or a year. At least we know they're working on it.”

Meanwhile, the coding committee has returned to the larger task of helping to develop national codes for pediatric rehabilitation products, Hostak says. The deadline for submitting code applications is April 1 of any given year, which leaves one more year to submit applications before the Health Insurance Portability and Accountability Act goes into effect.

In the future, new national codes and new wheelchair seat codes will create a better environment for everyone in the home health industry, Margolis says. “In the short term, however, [these changes are] just going to confuse everybody.”