Coalition rallies against new criteria for K0011s

Saturday, January 31, 2004

BALTIMORE - A coalition led by the big three wheelchair manufacturers, AAHomecare the Scooter Store and other providers is agitating for CMS to rescind a Dec. 9 guidance issued by the four DMERCs that spells out coverage policy for the K0011 power wheelchair.

The fledgling coalition was not prepared to declare itself by press time, but its protest against the new policy is likely to mirror objections that AAHomecare raised in a Dec. 23 letter to Angela Brice-Smith at CMS.

While the DMERCs and CMS argue that the Dec. 9 guidance was a clarification of existing policy, its critics say the DMERCs have created new policy but have failed to issue a draft of that policy for public review and comment.

“We therefore kindly request that CMS instruct the DMERCs to suspend implementation of these new policies until we, and other interested parties, have an opportunity to meet with you,” the AAHomecare letter states.

CMS plans to respond to the industry’s objections in a letter not available by press time. In the meantime, Region D Medical Director Robert Hoover said the national policy for wheelchairs has not changed, and so there’s no need for notice and comment.

“This was not a situation where we felt that public or industry input was necessary,” Hoover wrote in an e-mail to HME News. “There was no change in the LMRP (local medical review policy). The LMRP already has language that gives definition to the term ‘bed or chair confined’ as ‘a patient who requires a power wheelchair usually is totally nonambulatory and has severe weakness of the upper extremities due to a neurologic or muscular disease/condition.’”

In Region D, Hoover has historically sanctioned power wheelchairs for individuals who could take one to two steps for transfer between bed and chair or chair and commode. He doesn’t expect the Dec. 9 bulletin to cause much change in Region D and at least one other region.

The clarification could have a dramatic impact in Region C, which approves claims for four to seven times as many K0011 power wheelchairs than the other DMERC regions and where a more liberal interpretation of bed or chair confined has guided coverage decisions in recent years.

Because the Dec, 9 bulletin would have such a dramatic impact in Region C, the Power Mobility Coalition’s director, Eric Sokol, believes the guidance is tantamount to a policy change.

“It is a wholesale change,” Sokol said. “It is more than just the definition of ambulatory, but also the devaluing of the CMN, and also the establishment of a system where claims are in limbo status until they reach medical review.”

The DMERCs have reserved the right to apply the Dec. 9 clarification to all claims regardless of date of service. That stipulation spells trouble for companies that have historically relied heavily on the CMN as sole justification for the delivery of a power wheelchair.

In the bulletin, the DMERCs make clear that they consider the CMN to be a “medical review screening tool.” For claims under review, the DMERCS are looking for additional medical documentation to verify that coverage criteria have been met.

Those requests for documentation run counter to the PMC’s interpretation of documentation requirements for power wheelchairs.

“From the get-go, I can see this clarification going beyond mere clarification into the realm of changing policy because everyone assumes the CMN is what’s required, as long as it’s signed by attending physician,” said Sokol. “This clarification says no, it’s just a screening a tool.”