CMS, DMERC officials disagree over PWC policy

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Sunday, August 7, 2005

WASHINGTON -- Debate within CMS and the DMERCs over proposed new rules governing wheelchair policy could delay Medicare's effort to implement new codes, allowables and documentation requirements on Jan. 1, 2006.

The key word here is could -- and that depends on who you talk to. On Aug. 1, CMS was scheduled to issue a draft local coverage determination for mobility assistive equipment (POVs, manual and power wheelchairs). The LCD covers coding, coverage criteria and documentation requirements.

"There are differences of opinion among the medical directors on how conservative the coverage policy should be," said one industry insider. "The draft is at CMS and there are some significant issues that need to be resolved."

At least one DMERC medical director called Aug. 1 the drop-dead date for issuing the LCD. Issuing it any later jeopardizes the Jan. 1 implementation. That's because the draft comes with a 45-day comment period, and CMS must address the comments, which are sure to be numerous, before going live with a final policy.

"There are differences of opinion among the medical directors on how conservative the coverage policy should be," said one industry insider. "The draft is at CMS and there are some significant issues that need to be resolved."

DMERC and CMS officials declined to comment on this issue or say when the LCD might be issued.

Invacare's Vice President of Government Relations Cara Bachenheimer said she doesn't think the hold-up will delay the new wheelchair policy. Even if CMS doesn't release the draft LCD until early to mid September, "a lot of people think the Jan. 1 timeframe can be met," she said.

Among other things, the LCD should, industry leaders hope, explain more clearly what documentation justifies medical necessity for a power wheelchair. Uncertainty over documentation has led to a wave of denials and cries from providers, HME manufacturers, clinicians and consumer groups that patient access has been severely restricted.

"Suppliers want to know what the rules of the road are and have some assurance that when they provide the documentation and submit the claims to CMS they will get paid," said Seth Johnson, Pride Mobility's director of government relations.

If CMS doesn't issue a final LCD by Jan. 1, it may consider implementing the new codes and allowables, and use the existing coverage criteria until a final LCD is issued, say some industry watchers. Others, however, say they expect that come Jan. 1 it will be all or nothing, that CMS will continue with its existing policy until everything is finalized.

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