Separate benefit for complex rehab: New details include payment methodology

Thursday, October 7, 2010

BUFFALO, N.Y. - A clearer picture of the separate benefit for complex rehab is beginning to take shape.

During a webinar last week, Rita Hostak, steering committee member and vice president of government relations for Sunrise Medical, said a new payment methodology would be included in the legislative language for a separate benefit. For existing complex rehab codes--those that would be moved over from the DME benefit--a modified gap-filling methodology would be applied to re-price codes to include the CPI updates awarded to orthotics and prosthetics since 2000. The new pricing would be limited to a floor of the current fee schedule and a ceiling of 10% above the current fee schedule.

"We looked at, does it make sense to have reimbursement for the HCPCS codes and then create another code that would allow for billing of some of the face-to-face services that are provided?" Hostak said. "At the end of the day, the decision was made that no, it's not just the face-to-face time, it's the operational cost related to providing complex rehab. It's the process and procedures that make the cost very different than a DME company's cost. It really makes sense to come up with a formula that is going to allow for these items and services to be paid in one lump sum based on a HCPCS code."

The payment methodology was included in a new "proposal paper" published by the steering committee on Sept. 30 and reviewed by members during the webinar. To read the paper, go to

Committee members explained that, while the gap-filling methodology has flaws, it's one that CMS is familiar with.

"Instead of trying to create a dramatically different system, what we've done is, we feel, propose some rational modifications to it that should make it rational both for current codes and new codes that might be created down the road," said Don Clayback, chairman of the steering committee and executive director of NCART.

Other new details:

Supplier standards

Eventually, the new benefit would require suppliers to have additional qualifications beyond the assistive technology professional (ATP) designation, but that qualification is still to be determined.

"At least for the initial period, this will probably use standards that are currently out there and, over a period of time, we will have a transition so that we can allow individuals to secure this new qualification, whatever that qualification will be," said Simon Margolis, steering committee member and executive director of NRRTS. "That's still very much in the discussion phase and this is a very good time for people to weigh in on this."

Part of those discussions: RESNA's new seating and mobility specialist (SMS) certification and an enhanced version of NRRTS's certified rehabilitation technology supplier (CRTS) credential.

Bill of rights

The committee has drafted a bill of rights that outlines the required components that must exist to create an appropriate system for the coverage and payment of complex rehab, taking into account the needs of consumers, clinicians and suppliers. One of those components: "Clinicians and suppliers require the option to obtain prior funding approval for uncertain coverage situations."

"The idea of having a bill of rights was to create a single document around which consumers, suppliers and clinicians could rally," said Paul Tobin, steering committee member and president and CEO of the United Spinal Association. "Our hope, and what has been our experience to date, is that you get broad-based support on a single document, which will allow the three parts of this supply chain to advocate for a separate benefit category to protect complex rehab technology from further cuts."