CMS revises coverage criteria for PMDs--again

WASHINGTON - Providers breathed a small sigh of relief last week, when CMS further revised its coverage criteria for power mobility devices to address what the industry believed were two big flaws. After discussions with stakeholders, CMS dropped the "stand-and-pivot transfer" requirement for complex PMDs. The agency also expanded the number of PMDs that are eligible for advance determination for Medicare coverage (ADMC). "(The revised coverage criteria) isn't perfect, but, by and large, it's a significant improvement," said Cara Bachenheimer, vice president of government relations for Invacare. Still, it was hard for the industry to celebrate. In addition to new coverage criteria, CMS plans on Nov. 15 to implement new pricing that slashes reimbursement by up to 41%. "What good is better policy when the pricing is so bad?" asked Eric Sokol, director of the Power Mobility Coalition. CMS revised its coverage criteria once before. In September, the agency eliminated language that would have automatically downcoded beneficiaries from more- to less-complex PMDs. In its November revision, CMS replaced the "stand-and-pivot transfer" requirement with this: To qualify for a group 3 power wheelchair, the beneficiary's mobility limitation must be due to a neurological condition, myopathy or congenital skeletal deformity. "We're comfortable with that," said Sharon Hildebrandt, the executive director of NCART. "There are many beneficiaries, like those with multiple sclerosis, who can do a stand-and-pivot transfer, but they still need the configurations and capabilities of a group 3 wheelchair to function as independently as possible." To expand the number of PMDs that are eligible for ADMC, CMS will accept requests for single- and multiple-powered wheelchairs in groups 2 through 5, even if they don't have power seating systems. Right now, a power wheelchair must have a seating system to be eligible for ADMC. "This will permit advance determination for a patient with a progressive neurological disease who does not yet need a power seating system but the documentation from the face-to-face exam supports the need for such a system in the future," CMS states. There's still one part of the coverage criteria that worries the industry: By April 1, 2008, CMS plans to require that assistive technology practitioners (ATPs) conduct face-to-face exams for certain power mobility devices. Conceptually, the industry supports this idea, but it fears there aren't enough ATPs to comply with the requirement, said Seth Johnson, chairman of AAHomecare's rehab council and vice president of government affairs for Pride Mobility.