Cushion fees still plague providers; beneficiary access hangs in doubt

Friday, December 31, 2004

WASHINGTON - The updated Medicare allowables for wheelchair back and seat cushions are still inadequate and threaten patient access, say rehab officials.

On top of that, ICD-9 diagnose codes required for some of the products are too limited. That means patients who need the products but fall outside the approved diagnoses could be denied access. Or, providers will have to appeal the denials and wait months to get their money, said Matthew Burke, chair of AAHomecare’s Rehab and Assistive Technology Council.

“For a company to order product, get it in, put it together, deliver it, bill for it and get paid, the process has to work perfectly,” Burke said. “Now you throw in this thing where the cushion is going to get denied and payment delayed, well, the profit that is there doesn’t support the activity of chasing down the money anymore.”

RATC sent a letter Nov. 29 to CMS pointing out the problem and requesting that Medicare officials work with them to broaden the diagnoses codes for positioning and skin protection cushions and backs. Those are the two main categories of products with an access problem due to limited ICD-9 codes, according to RATC.

In late October, providers cheered CMS’s action to update its interim fee schedule for seat and back cushions. In many cases, however, the new allowables proved not much better than the old.

Despite the continuing problems with the codes, industry leaders have taken heart in CMS’s willingness to work with them to develop the allowables. The current allowables are scheduled to be update Jan. 1. The one exception: Permanent HCPCS codes and allowables for adjustable products now assigned to K0108 will be released in April.

Unfortunately, until CMS changes how it calculates new allowables, “we aren’t going to get decent fee schedule rates,” said Sharon Hildebrandt, executive director of the National Coalition for Assistive Rehab Technology. “We are talking to CMS and the DMERCs on this and are hoping that we can get something that is more realistic.”

When establishing new allowables, CMS uses “gap filling,” which deflates a product’s price back to what it was or may have been in 1986. From there, CMS uses a formula that considers annual CPI increases to determine the new price. Providers and CMS officials both acknowledge gap filling can create inadequate allowables.