Power Wheelchair Coding

Thursday, September 30, 2004

By now everyone is aware of efforts by CMS to modify the current code set for power wheelchairs. The idea of new power wheelchair coding and its implications have many people scrambling to understand the proposals submitted by the National Coalition of Assistive and Rehab Technology (NCART) and the CMS proposal. After more than a decade working with the current K-codes, it is difficult for some people to understand why this change is needed. Others, just want to interpret the proposals and anticipate how the changes could impact their business.

Because of my involvement with the NCART coding proposal, I am often approached with questions regarding the two proposals. The question I hear most is, “how does the NCART proposal differ from CMS’?. The answer is fairly simple. A key distinction between the two proposals is that the CMS proposal has a bright line distinguishing basic wheelchairs from “rehab” wheelchairs. NCART believes that technology differences are in shades versus a bright line. The NCART proposal includes a code that represents the level of technology that is in between the most basic and the most complex. NCART believes that not only are the technologies distinguishable, but the people that need them are as well.

Another difference is that CMS is proposing a structure similar to the old E-codes for manual wheelchairs. There is a code for each configuration versus a base code plus add-on codes. For example, instead of using a code for seat widths greater than standard, CMS is proposing a separate base code that reflects both the base and the seat width. A result of this structure is that the CMS code set is considerably higher in number than the NCART proposal. This structure is one that has positives and negatives and consideration must be given to all angles.

There are other critical differences between the two proposals, many of them are down in the details of the code definitions. Issues such as the required patient weight capacity, minimum testing criteria and seat widths and depths which are included in the base wheelchair. These may seem like little details, but they can mean the difference between adequate pricing and pricing so insufficient that choice is eliminated or worse, access denied.

The fact is that the final code structure, code definitions, and possibly the Medicare fee schedule, will be adopted by the Medicaid programs. This increases concern for all stakeholders. The concern is partially due to the fact that people with complex and severe disabilities are frequently served by Medicaid.

The next question I hear is, “Is there anything in the CMS proposal that scares you?’ I am concerned about the recommendation in the CMS proposal for “basic packages.” These “basic packages” would essentially bundle items that have historically been billed at a high frequency to the DMERCs. They are wheelchair accessories such as, seat belts, batteries, wheel locks, foam filled tires etc. The concept of packages concerns me because it could result in inadequate pricing which could reduce product choice. Moreover, this concerns me because all payers would automatically reimburse for items that may not be medically necessary.

By the time this article is published, the public meeting scheduled for Sept. 1, 2004 will have already occurred. NCART and CMS will have presented their coding proposals to those in attendance. Many clinicians, consumer advocates, suppliers and manufacturers will have had an opportunity to provide their comments. It is unlikely, however, that we will know the outcome. There will still be a lot of work to do. Not only will final coding decisions need to be made, code characteristics (the features that allow people to know what products fit what codes) will have to be established, pricing will be developed and more than likely a new medical policy will be announced. In short, there is a lot of work still to be done.

One final question: “What do I hope the coding outcome will be?” After three years of work on this proposal, I can safely say that what I want, and what I believe every member of the taskforce wants, is the same thing we wanted when we started this project: A power wheelchair code set that will ensure access to appropriate technology for people with mobility and postural impairments, and one that will do so in a responsible, reasonable, equitable and cost-effective model. NCART would like to work with CMS, hopefully in a collaborative manner, to find this balance in a new code set.

- Rita Hostak is vice president of government relations at Sunrise medical and president of the National Coalition for Assistive and Rehab Technology.