CMS backs off cushion allowables

Tuesday, November 30, 2004

WASHINGTON - Rehab providers breathed a sigh of relief in late October when CMS scrapped unrealistically low allowables for key seating products and announced it would base payment for those items on individual consideration.
As of Oct. 25, any adjustable skin and combination cushions previously assigned by the SADMERC to codes K0652/K0653 (adjustable skin protection) and K0656/K0657 (adjustable skin and positioning) will be reassigned to the K0108 miscellaneous code. Reimbursement for products in these four codes will be based on individual consideration of the submitted charges.

The SADMERC also announced that the allowables for K0658 and K0666 HCPCS codes (custom molded seat and back respectively) have been changed to individual consideration.

Providers and manufacturers cheered both moves.

“We are pleased because Medicare recipients can now get the products they need,” said Patrick Meeker, clinical applications manager for The Roho Group. “Providers were in an ethical quandary. Did they provide the product they knew the client needed or a product they knew they could get paid for?”

On July 1, 20 new K codes covering wheelchair seat and back cushions and some accessories went into effect, but providers didn’t have to start using them until Oct. 1.

Originally, CMS intended to attach allowables to the new codes on Jan. 1, 2005. During the three months between Oct. 1 and Jan. 1, 2005, providers expected CMS to use the codes but to consider products individually for pricing. Instead, CMS developed an interim fee schedule, which was to be in place until Jan. 1.

CMS’s formula for developing new allowables is based on the median price of products in a particular code. Because many products had not yet been assigned to the new K codes, the allowables did not accurately reflect retail prices, particularly for higher-end products, the industry argued.

CMS listened.

“They understood that access was going to be denied to beneficiaries because of the allowables they came out with, and they couldn’t have that,” said Sharon Hildebrandt, executive director of the National Coalition for Assistive Rehab Technology. “They understood that was the reality. It wasn’t the industry crying wolf.”

As more products are assigned to the seating codes, CMS will use the larger pool of pricing data to refigure - in January, April and possibly July - new allowables for the seating codes. HME

CMS’s decision to reprice the codes is also important because many state Medicaid programs discount their allowables off the Medicare fee schedule, said Matthew Burke, chairman of AAHomecare’s Rehab and Assistive Technology Council.

“This was a really big issue, and it has been resolved,” Burke said.