Baltimore
CMS' long-awaited National Coverage Determination for mobility equipment eliminates the requirement that Medicare beneficiaries be bed- or chair-confined and instead adopts function-based criteria for determining medical necessity.
The new policy, effective after its release May 5, determines coverage based on how well a beneficiary can perform activities of daily living, such as toileting, grooming and eating. It takes prescribing physicians or clinicians through a series of questions to determine which mobility-assist device — encompassing a range of equipment from 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.
“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.”
While this portion of the policy is welcome news to many stakeholders, others are disappointed the policy continues to limit wheelchair coverage to beneficiaries who need the equipment primarily in the home. According to the CMS decision memorandum, however, the in-the-home restriction comes from the Medicare statute, so “an NCD would not be the appropriate mechanism to change that [rule].”
Laura Cohen, a clinical research scientist at the Shepherd Center in Atlanta, is also concerned that CMS does not consider mobility itself an activity of daily living, such as grooming or bathing. “[CMS] says that by itself, [mobility] does not serve a medical purpose,” said Cohen, co-coordinator of the Clinician Task Force of the Coalition to Modernize Medical Coverage of Mobility. “It's ironic that a wheelchair isn't being acknowledged as necessary for [someone to attain] mobility.”
Others are concerned the NCD does not explain necessary documentation. “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,” said Eric Sokol of the Washington, D.C.-based Power Mobility Coalition.
According to a decision memo, CMS planned to address the documentation issue separately. The DMERCs were expected to issue interim guidance for providers, but as of press time, the guidance had not been released.
The NCD is posted on CMS' Web site, www.cms.hhs.gov.
In a Nutshell
According to the Mobility NCD:
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“Bed-or-chair confined” language is eliminated and replaced with function-based clinical criteria for determining the medical necessity of a mobility device.
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Beneficiaries must have a medical need to use a mobility device in the home in order to be covered under Medicare.
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Activities of daily living include eating, grooming, bathing and toileting, but mobility itself is not included.
Key mobility directives to come:
- Face-to-face physician exam requirement
- Revised POV policy
- New wheelchair CMN
