CMS won’t budge on K0011s

Wednesday, March 31, 2004

WASHINGTON - CMS has dug in its heels and continues to refuse industry demands that it rescind a December “coverage clarification” that restricts power wheelchairs to beneficiaries who are bed- or chair-confined.

Tim Hill, Medicare’s chief financial officer, called the heightened scrutiny of PWC claims and the renewed emphasis on the bed- or chair-bound criteria an effort to control skyrocketing utilization. The clarification is not, as the industry claims, a policy change requiring a notice and comment period, according to Hill. It’s been part of the national coverage criteria since 1995, he said.

“We have heard a lot about asking the DMERCs to back off on reviewing claims and asking the DMERCs to withdraw the Dec. 9 statement,” Hill said last month. “But that would be meaningless because the national policy would still be the same.”

Hill suspects the Dec. 9 clarification upset the HME industry because providers are not used to the increased scrutiny of power chair claims.

To Hill, bed- or chair-bound means “you are not usually able to ambulate and without a wheelchair would have to spend the preponderance of your day in a bed.”

That vagueness in coverage criteria and a renewed dedication to reviewing documentation beyond the CMN - especially a doctor’s notes that emphasize a patient’s chair- or bed-bound condition - has had a chilling effect on some providers. If the doctor’s notes don’t allude to a beneficiary’s bed- or chair-bound condition, they won’t provide the chair.

That may limit denials, but it also denies access to beneficiaries who can ambulate around their homes but do so unsafely and risk falling, said Pride Mobility Products President Dan Meuser.

“If I were a supplier, I would feel the same way,” Hill said. “They are anxious to have a very strong clear set of objective criteria that will tell them definitively when a claim will be paid. It’s vague and subjective, but these are clinical judgements that need to be made. It depends on individual patients and what the physician believes about their need for the wheelchair and the need to get around the home.”

In an effort to rescind, the chair- or bed-bound criteria, Invacare, AAHomecare, the MED Group, Mobility Products Unlimited, Pride Mobility, the Scooter Store and Sunrise Medical have joined forces and created a coalition, Restore Access to Mobility Partnership.

The group claims that rather than a coverage clarification, CMS’s decision to limit power wheelchairs to bed or chair-bound beneficiaries is a restrictive policy change.

“The government needs to rescind this coverage restriction,” said Cara Bachenheimer, Invacare’s vice president of government relations. “I don’t think anyone disagrees some clarification is necessary, but let’s do it in a reasonable way. Let’s involve all the affected constituencies - the consumers, the clinicians and the industry - and have a real discussion with meaningful input. Let’s rescind it until that is resolved.”

According news reports, RAMP members have committed $250,000 for its lobbying campaign.

One politician who has acknowledged the industry’s concern is Sen. Charles Grassley, R-Iowa, chairman of the powerful Senate Finance Committee. In a Feb. 25 letter to CMS, Grassley asked bureaucrats to explain how they developed the December coverage clarification.

“While ensuring that we do all that we can to eliminate fraud and waste from government programs,” Sen. Grassley wrote in a letter to CMS. “I also want to be certain that we are not inappropriately preventing our eligible citizens from obtaining the medically-needed equipment they are authorized to receive.”