New codes chart the best course for stability

Friday, April 30, 2004

R. Hostak

The power wheelchair industry is currently operating under an antiquated reimbursement system that does little to encourage the development of new technology or ensure that more efficient equipment - that could save millions of dollars each year in associated healthcare costs - reaches people with all levels of disabilities.

At the core of the problem are HCPCS codes that are inadequate in terms of defining existing technology and are not aligned with clinical applications or consumer needs. The distinguishing features that determine technological appropriateness are just not represented in the current code set. Here’s an example: Instead of considering factors, such as the ability to accept alternate drive controls or powered seating systems, the codes use the “weight’’ of the chair as a major distinguishing factor. Quite obviously, this needs to be changed to a standard more reflective of existing technology and its benefits to consumers.

Unfortunately, the industry’s history of dealing with CMS on coding issues has left some companies lacking confidence that the outcome will be appropriate. The process for requesting a modification to the National HCPCS code set is, by design, segregated from pricing and coverage. However, the impact of their integration can be destructive to the industry and deny consumer access.

The risk is that the industry could end up with new HCPCS codes but inadequate reimbursement or unreasonable coverage policies. In this instance, the system could be altered in a way that would limit eligibility for a product to a standard power wheelchair. Everyone would lose: industry would get little incentive to produce and sell better equipment; patients would be deprived of greater mobility; and it would ultimately cost taxpayers more money because Medicare pays thousands of dollars more each year to treat each immobile or improperly positioned senior citizen.

Some predict that tinkering with the K0011 code would divide the technology between high-tech equipment and the equally important standard technology. The concern is that this would also divide the industry along similar lines making the power wheelchair industry no longer unified, a situation that is not at all desirable. While these are legitimate concerns, they can also be mitigated. There are important reasons to press forward, advocating for fair and meaningful change.

Recently, the industry formed the RAMP Coalition to confront the DMERC’s December clarification that redefined the Medicare coverage policy, limiting reimbursements. We have seen how much we can accomplish when we work together, including all stakeholders. We will stay together, deploying a united engagement on important issues.

Further, the HCPCS Code K0011 is not the glue that is holding the industry together: there is a higher force. The industry is unified by the desire to serve the full range of people that require medical technology, the desire to have clear guidelines for coverage, the desire to know that when a product is provided reimbursement should follow and the desire for transparent requirements regarding support documentation that proves medical need.

Both the industry and the government share an obligation to make every effort to ensure consumer access to all levels of technology. As it stands today, the K0011 code represents a broad range of technology and is used for claim submission for all payers. Developing new codes that accurately describe current technology will facilitate the development of clinically sound coverage policies. This is broader than a Medicare reimbursement issue; it impacts all stakeholders.

In reality, coding is the foundation that can provide stability to the power wheelchair marketplace. To achieve an appropriate outcome for the industry, consumers and the government, the codes must define current technology in terms that are meaningful and that align with clinical application.

The industry cannot cling to the status quo, hoping nothing will change. It’s clear the power wheelchair market is changing with or without our input. The choice is to help define the future or be defined by it. The smart move is for the industry to spearhead the change and use the process to provide information and recommendations that facilitate a positive outcome for suppliers, payers and most importantly, consumers.

The greater risk is to not take action. Maintaining access to all levels of medically necessary technology is the only appropriate outcome for the consumers, with many levels of disabilities that we serve. New codes are the best course towards establishing meaningful, long-term stability for the market, and ensuring that consumers have access to a full range of products that can meet their needs and improve their quality of life.

- Rita Hostak is v.p. of government relations at Sunrise Medical and president of the National Coalition for Assistive and Rehab Technology