Medical Device Daily

In a move obviously intended to diffuse recent and ongoing controversy concerning which Medicare beneficiaries should or should not get power mobility equipment – such as powered wheelchairs and scooters – the Centers for Medicare & Medicaid Services (CMS; Baltimore) last week rolled out new criteria for reimbursement of this equipment. The new national coverage determination (NCD) focuses on what CMS termed “a function-based determination of medical necessity.”

But the new guidelines go beyond the reimbursement for the powered wheelchair sector. Rather, according to the agency, it is “three-pronged,” with the new guidelines covering reimbursement for products ranging from the powered and manual wheelchairs to even canes and crutches, and totaling 13 product categories.

For the power mobility equipment industry, the new criteria are the most significant fallout from the “Wheeler-Dealer” effort launched by the Department of Health and Human Services (Washington) in 2003 (Medical Device Daily, Sept. 11, 2003). That program was designed to cut down on the ballooning reimbursements for the power devices, which HHS said been driven by fraudulent reimbursement billing.

As an example, one estimate indicates that in 2001 Medicare paid for 3,000 wheelchairs in Harris County, Texas, alone (primarily the Houston area), with that number jumping to 31,000 in 2002, or more than 900%. At roughly $5,500 a chair, that was an increase from about $16.5 million to more than $170 million.

In cracking down on these reimbursements, however, the agency raised the ire of the power chair and mobility companies who said that the traditional guidelines – which set a patient “bed- or chair-confined” standard – were too narrow and needed to be revised using clinically based standards that would benefit those truly needing the mobility equipment.

The new decision, specifically relating to “mobility assistive equipment” (MAE), CMS said, will target beneficiaries “who have a personal mobility deficit sufficient to impair their participation in mobility-related activities of daily living, such as toileting, feeding, dressing, grooming and bathing in customary locations in the home.”

Such deficits, it said, “will use an algorithmic process . . . to provide the appropriate MAE to correct the mobility deficit.”

CMS said the new coverage criteria also would come with new billing codes that will take effect next Jan. 1. It said the new codes will “reflect the variety of wheelchairs now on the market.” Additionally, it will issue “new quality standards” for suppliers in 2006.

Barry Straube, MD, acting chief medical officer and acting director of the Office of Clinical Standards and Quality, said that the new 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.” He emphasized also a consistency between “documentation of the functional needs of the patient” and the appropriate medical records.

In order to help practitioners understand the new criteria and the methods of documenting the needs of beneficiaries in their medical records, the agency said it will be issuing additional guidances. In general, this will make the power mobility coverage process “more straightforward.”

Kimberly Brandt, director of CMS’s Program Integrity Group, said that in the effort “to root out fraud and abuse,” CMS had concluded that “there are more accurate tools” than provided in current policies. “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. Most accurate claim submission will allow CMS to better analyze claims data and focus claims review to target abusive billers.”

Mark McClellan, CMS administrator, said the new criteria “reflect current medical practice and mean that beneficiaries will have the freedom to live better, more mobile lives, without needing to fit in to a rigid ‘bed- or chair-confined’ standard.”