CMS expands seating policy

WASHINGTON--The rehab industry scored a swift victory June 18, when the DME MAC medical directors agreed to tweak the local coverage determination (LCD) for wheelchair seating.

U.S. Rehab's Peggy Walker sent the medical directors a packet of information, including case studies, in May, asking them to add certain diagnoses to the list of conditions that qualify patients for skin protection cushions, and seat and back cushions. About six weeks later, the medical directors responded to Walker, telling her they would add some but not all of the diagnoses.

“We appreciate them doing this and doing it as quickly as they did, especially with so much going on,” said Walker, a billing and reimbursement adviser for U.S. Rehab, a division of The VGM Group. “I think the way we presented our case, it just made sense. It's not suppliers saying, 'We're not getting paid.' It's a patient access issue.”

For skin protection cushions, approved diagnoses will include 342.0 hemiplegia/hemiparesis, 333.4 Huntington's chorea, 333.6 idiopathic torsion dystonia, 333.71 athetoid cerebral palsy and transverse myelitis. For seat and back cushions, they will include 879 traumatic amputation of leg (complete or partial), 756.51 osteogenesis imperfecta and transverse myelitis.

The medical directors didn't set an implementation date for the changes in their letter to Walker.

Under the existing LCD, therapists like Cindi Petito say they're limited in what cushions they can recommend for patients about 50% of the time.

“It happens often,” said Petito, an OT and ATP who owns Seating Solutions in Jacksonville, Fla., who helped Walker collect and submit information to the medical directors. “For example, if I have a stroke patient who has hemiplegia and no other qualifying diagnosis for a cushion, I can recommend only a positioning cushion, not a skin protection cushion, and what's available for positioning cushions is very limited. This will help us provide patients with more appropriate cushions.”

The industry plans to continue working with the medical directors to further tweak the LCD so it's more clinically driven, not diagnosis driven. Walker attached to her packet of information a request from The Clinician Task Force to that effect.

“The task force proposes additional coverage criteria that would be based on function,” said Elizabeth Cole, director of clinical rehab services for U.S. Rehab, who also helped Walker. “If patients have a clear need for skin protection cushions, backed by a clinical evaluation and documentation, that should qualify them for the cushions, even though they don't have one of the listed diagnoses.”