BALTIMORE--CMS' national coverage determination for mobility equipment, announced late last Thursday, eliminates the requirement that Medicare beneficiaries be bed- or chair-confined and instead adopts function-based criteria for determining medical necessity.

Medicare's new coverage policy, effective immediately, hinges on how well a beneficiary can perform activities of daily living such as toileting, grooming and eating. It takes clinicians through a "stepped" process to determine which mobility-assist device--encompassing a range of equipment from canes and walkers to scooters and power wheelchairs--is medically necessary.

"This coverage policy ensures that a beneficiary's functional status and individual circumstances are considered so that the most appropriate technology for each beneficiary's personal needs is covered," said Barry Straube, CMS' acting chief medical officer and acting director of the office of clinical standards and quality. "It is also consistent with the documentation of the functional needs of the patient that should be in medical records for our beneficiaries."

The policy continues to limit wheelchair coverage to beneficiaries who need the equipment primarily in the home--a sticking point for HME industry stakeholders. But according to the CMS decision memorandum, the in-the-home rule comes from the Medicare statute, so "an NCD would not be the appropriate mechanism to change that [rule]."

The coverage decision is part of Medicare's larger three-pronged overhaul of its mobility benefit, begun in 2004 and since dubbed the Modern Mobility Initiative, which focuses on coverage, payment and supplier quality standards. In February, the agency introduced 49 new billing codes for power chairs and scooters that will take effect Jan. 1, 2006. According to a tentative schedule released earlier this year, CMS has also said it expects to issue new quality standards for suppliers by this summer.

But some pieces of Medicare's new mobility reimbursement puzzle are still missing. Industry insiders had expected the new coverage policy to be released with several other elements of the initiative, including a face-to-face physician exam requirement and a new wheelchair Certificate of Medical Necessity.

"This was supposed to come out as a coordinated package that would take care of all of the issues," an agency spokesperson told HomeCare Monday. However, the NCD was released separately because it had a deadline dictated by the Medicare Modernization Act. The spokesperson added that "it is a very high priority to get the rest of the coordinated package out."

The government also has yet to release documentation guidance for providers who must show that beneficiaries meet medical necessity requirements for mobility equipment. According to the agency's decision memo, "While CMS does require adequate documentation to establish that coverage conditions are met, the complexity of the issues indicate that this is best addressed in an initiative separate from the NCD."

A press release from the agency said CMS plans to issue additional guidance "in the near future to help physicians and treating practitioners better understand the new coverage criteria and CMS' expectations about proper documentation in the medical record. Because the new functional criteria more explicitly refer to standard clinical evaluative methods, CMS expects that the medical documentation generated during the patient evaluation will more accurately be reflected in the beneficiary's medical record. It is CMS' intent that this will make the power mobility device coverage more straightforward."

"During the course of reviewing Medicare's policies for power mobility equipment, CMS came to the conclusion that there are more accurate tools to root out fraud and abuse," said Kimberly Brandt, director of CMS' Program Integrity Group. "The combination of the new NCD and the planned enhanced educational outreach by Medicare to physicians and treating practitioners, as well as to suppliers, will eliminate most honest billing errors. More accurate claim submission will allow CMS to better analyze claims data and focus claims review to target abusive billers."

In the meantime, the DMERC medical directors are working on a transition article to be posted on the DMERC Web sites. "In the transition article, you'll see [how] the existing CMN will be used ... in line with the new national coverage determination," said Dr. Robert Hoover, medical director for the Region D DMERC. "All those details are still being worked out aggressively."

Although a new wheelchair CMN is still under consideration, the transition article will refer only to the wheelchair CMN currently in use, he said, adding that he is hopeful the interim guidance will be posted "shortly."

On Friday, industry reaction to the mobility NCD was mixed. Some praised the elimination of "bed- or chair-confined" language but expressed concern about the lack of documentation guidance. Others said they were disappointed that the policy does not treat mobility itself as an activity of daily living.

• "We're very excited," said Dan Meuser, president of Pride Mobility, Exeter, Pa. "It is indeed night and day from the previous ... archaic 'bed- or chair-confined' policy. It's almost like the Wicked Witch is dead. There are concerns with documentation clarity that still exist. However, we do expect the DMERCs to understand there is a new, clearer coverage policy; therefore, new, clearer documentation requirements should be reflective of this new policy."

• "We are pleased at what we saw," said Eric Sokol of the Washington, D.C.-based Power Mobility Coalition. "We are disappointed that CMS did not provide [guidance] for current and pending claims. This NCD is only for times moving forward. Providers are still in the dark," Sokol said, regarding what documents prove medical necessity for a wheelchair. "It is our hope a new [wheelchair] CMN will ensure suppliers have more than a reasonable explanation of what documents meet eligibility criteria."

• Laura Cohen, a clinical research scientist at the Shepherd Center in Atlanta, said that though the policy does treat activities like grooming and bathing as activities of daily living, CMS does not consider mobility itself as such an activity. That, she said, could create problems for clinicians. "[CMS] says that by itself, [mobility] does not serve a medical purpose. It's ironic that a wheelchair isn't being acknowledged as necessary for [someone to attain] mobility." Cohen is also co-coordinator of the Clinician Task Force of the Coalition to Modernize Medical Coverage of Mobility.

• According to Barbara Crane, CTF co-coordinator and professor at Hartford University, "Environmental considerations are essential in order to match an individual to the appropriate technology solution," she said. "The new NCD ties our hands and confines clinical practice to the confines of the home."

• A statement from the Restore Access to Mobility Partnership--a coalition that includes the American Association for Homecare, Invacare Corp., the MED Group, Mobility Products Unlimited, Pride Mobility and Sunrise Medical--echoed the clinicians' concerns. While the new NCD is "a step in the right direction," the statement read, "Clinicians, as well as advocates for people with disabilities, have repeatedly advised CMS that 'mobility for mobility's sake' should be treated as an activity of daily living. Giving a Medicare beneficiary increased mobility with a power wheelchair can be just as significant for an individual as using the equipment to improve the ability to get to the bathroom, eat, dress, groom or bathe. CMS also chose not to change the requirement that power mobility equipment be restricted to increasing a Medicare beneficiary's ability to perform activities in their home. This provision contrasts sharply with clinical practices ...

  "Lastly," the statement continued, "these new coverage guidelines make it imperative that a clear and comprehensive documentation process be quickly established so that all of the stakeholders--beneficiaries, doctors, clinicians and providers--have a full understanding of what medical documentation will be definitive for claims to be approved."

• "Our next steps? Documentation, documentation, documentation," said Cara Bachenheimer, vice president of government relations for Elyria, Ohio-based Invacare. "The DMERC medical directors are responsible for Local Medical Review Policies based on this national coverage determination, so there's an opportunity for the DMERCs to provide significantly more clarity than what now exists in the national policy."

The NCD is posted on CMS' Web site, available by clicking here.