Grand Poo Bah for a Day

On most days, each one of us could easily fix some of the biggest problems associated with third party payers and how they establish coding, coverage and payment for the products and services we provide. It's simply a matter of logic, understanding our business and crafting Medicare rules that are completely in sync with those principles.

This month, I am going to play the role of “Medicare Grand Poo Bah” and tell you what I would do to fix the biggest challenges we face in dealing with the program. Here's my priority list.

1. Fix the power mobility device benefit. When creating, improving or modifying any portion of the durable medical equipment benefit, the logical policy development is first to address coding of the products; second, to establish coverage criteria; third, to set the documentation rules; and fourth, to establish allowables for the new codes.

   Left to do today in my new role:

   • Establish new HCPCS codes and testing requirements for PMDs to ensure they are consistent with American manufacturers' products and the testing requirements currently in place by ANSI-RESNA standards. The codes need to include clinical application information to enable development of specific code coverage criteria based on the consumer's specific medical and other needs.

   • Provide meaningful documentation guidance for physicians, therapists and suppliers. The Interim Final Rule should be re-issued as a final regulation, incorporating the many public comments CMS received last year.

   • Draft the Local Coverage Determination to ensure beneficiaries have access to the PMD that meets their medical needs. We need not limit the appropriate PMD to one that is only functional in the home; we need to cover features for safety and independence when operating the PMD outdoors.

   We need to modify the assistive technology practitioner requirement (since there are currently an insufficient number of people with ATP certification) to allow a three- to five-year phase-in for compliance. We will also consider allowing a qualified occupational or physical therapist to perform the evaluation.

   • Establish equitable fee schedules for the new PMD HCPCS codes. Because the historic trend in power wheelchair prices is not represented by the price increases of the CPI-U, the use of gap-filling should take into account the actual pricing for power chairs since 1987.