New proposal digs deeper into wheelchair codes

Friday, May 30, 2014

WASHINGTON – Certain wheelchair codes not included in the current PMD demo project could be included in a new prior authorization program recently proposed by CMS.

Included in a “master list” of codes that could be included in the program are K4 lightweight manual wheelchairs and Group 3 power wheelchairs with power options. The PMD demo includes Group 3 power wheelchairs, but only those without power options, says Martin Szmal, founder of The Mobility Consultants.

The list includes codes from the PMD demo, but CMS states: “Since the proposed Master List containsDMEPOS items currently included in the CMS Prior Authorization of Power Mobility Device (PMD) Demonstration, we would not require prior authorization for PMDs under this proposed rule, at least until the demonstration was complete. This proposed rule would not affect the current Prior Authorization of PMD Demonstration.” The demo is scheduled to end Aug. 31, 2015, for all states.

Another difference between the prior authorizations required by the PMD demo and the proposed program: They would be mandatory.

“Most providers in the demonstration are treating it as mandatory because if you submit a claim without prior authorization in one of the seven states that is currently part of the demonstration and Medicare deems that claim to be payable, they pay it at a 25% reduced payment amount,” said Seth Johnson, vice president of government affairs for Pride Mobility Products. “The proposal does not have such a provision. It’s mandatory for payment.”

In a release, CMS pointed to the success of the PMD demo as the reason it is pursuing prior authorizations for other DME. It said the new program “builds upon lessons learned” from the demo.

“It does provide protection for the plan and the provider, so if it’s structured properly, it can be a positive thing for all involved,” said Don Clayback, executive director of NCART.

As for the PMD demo, CMS has released an FAQ with a few more details on its plans to expand to 12 additional states. The agency said the expansion will take place no earlier than Sept. 1, 2014. It also said the codes will remain the same under the expansion.