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More pieces of Medicare's mobility benefit overhaul came out of the box last month when CMS released draft coverage criteria and a bevy of power chair codes to take effect next year.
The coverage criteria draft eliminates the requirement that beneficiaries must be bed- or chair-confined to qualify for a wheelchair, but keeps intact Medicare's rule that limits coverage to DME primarily used in the home. At the same time, Medicare introduced 49 new codes for power chairs and scooters, breaking the broad K0011 code down to specific chair configurations.
Coverage Criteria
While most stakeholders have praised the new draft National Coverage Determination (NCD) — which spells out factors that qualify Medicare beneficiaries for mobility equipment — for its function-based standard of medical necessity, the in-the-home rule remains a sticking point.
“We were very disappointed that they failed to address the in-the-home restrictions, but it's what we expected,” said Barbara Crane, a physical therapist who co-chairs the Clinician Task Force, a group that has submitted coverage policy recommendations to CMS.
The agency explained that an NCD would not be the “appropriate mechanism” to change the rule.
Although the new NCD has provided many answers, questions still remain about how it will be interpreted. CMS plans to publish the final NCD and to provide guidance on how to use and document the new criteria this month.
New Codes
CMS has organized the new power chair codes into a number of groups and subgroups, dividing them into specific power chair configurations. All will go into effect Jan. 1, 2006, while existing power chair codes — K0010, K0011, K0012, K0014 — will be discontinued with no grace period or crosswalks. Regarding the new codes, “this is a phenomenal body of work that needs some small tweaking to create a situation where the industry is 100 percent better off than it was before,” said Simon Margolis, vice president of clinical and professional development for Chattanooga, Tenn.-based National Seating and Mobility. “We'll look back and say, ‘How did we ever live with those K0011s?’”
Before the codes take effect, manufacturers must submit products for tests that measure, among other things, weight capacity, fatigue, speed and range.
Putting Pieces Together
According to sources, CMS will soon start the most challenging part of revamping the mobility benefit — piecing the elements of the mobility puzzle together. These include developing specific documentation requirements from the coverage criteria, matching codes to available technology, assigning fees — something of great importance to providers — and educating stakeholders on the new system.
In a future regulation, CMS also plans to add a requirement for a face-to-face exam with the prescribing physician. A new wheelchair CMN also is under consideration.
For more, see Washington Wit & Wisdom on page 50.
To view the NCD, visit www.cms.gov and click “coverage” on the left menu bar. Click “tracking sheets,” then select “mobility assistive equipment.” View new codes at www.cms.hhs.gov/suppliers/dmepos.
