CMS CLARIFIES LOCAL COVERAGE DETERMINATION FOR POWER MOBILITY DEVICES, INCLUDING POWER WHEELCHAIRS AND SCOOTERS
MOVE PROTECTS ACCESS TO FULL RANGE OF TECHNOLOGIES FOR BENEFICIARIES
The Centers for Medicare & Medicaid Services (CMS) today issued clarifications of a local coverage determination (LCD) that outlines the process carriers are to use to determine the appropriate power mobility device (PMD). The coverage guidance is part of a long-term strategy to improve beneficiary access to the appropriate mobility assistance device, including power wheelchairs and scooters. The LCD, together with the new payment rates that CMS will be announcing soon, will become effective for PMDs furnished to beneficiaries on or after November 15, 2006.
After careful consideration, CMS has decided to make changes to its local coverage determination (LCD) to make clear that beneficiaries will receive the mobility technology to meet their comprehensive needs. The move to clarify this policy results from feedback from manufacturers, suppliers, and clinicians, that the current policy, as drafted, may not provide enough flexibility in providing a beneficiary the right PMD. The purpose of the LCD is to lay out the basic coverage criteria for PMDs and ensure that beneficiaries receive a PMD that is reasonable and necessary, considering their medical condition, functional ability, and home environment. With this in mind, one of the changes that will be made is to revise the language providing for a least costly alternative determination. This language was widely misinterpreted as a blanket down-coding of Group 2 (general use) to Group 1 (light weight) power wheelchairs. The LCD will be modified to incorporate this and other changes so that there will be no confusion surrounding the basic intent of Medicare’s policy. As result of these changes, the effective date for the new codes and LCD will be changed to claims with dates of service on or after November 15, 2006.
In addition, the clarified LCD will be issued by the durable medical equipment (DME) Program Safeguard Contractor (PSC) Medical Directors and will become available on the DME PSC web sites on September 20, 2006. This clarified LCD, which has been adopted by the DME Medicare Administrative Contractors (MACs), provides greater flexibility and ensures beneficiaries will receive the right PMDs for their medical conditions. The policy is available at the following websites:
Finally, the PMD codes, fee schedule amounts, and LCDs were originally scheduled to take effect on October 1, 2006. In order to allow for additional time to prepare for implementation of the fee schedule amounts and LCDs, these changes will be effective on November 15, 2006. Additional instructions from the DME MACs will be forthcoming.
Today’s announcement is the latest development in a comprehensive approach to power wheelchairs and power scooters paid for by the Medicare program that was first announced in April 2004. This strategy encompassed the development of new, functionally based coverage criteria for PMDs such as power wheelchairs and power scooters; development of new, more specific codes for billing and paying for PMDs depending on the particular characteristics of each type of equipment; and development of more stringent standards for the suppliers who furnish this equipment to beneficiaries.
The effort to improve Medicare policies for covering and paying for power wheelchairs was initiated in response to numerous instances of fraud and abuse, and significant growth in expenditures for these items under the Medicare program. From 1995 to 2003, expenditures for power wheelchairs increased by an astonishing 2,705 percent, from $43 million to $1.2 billion in just over just 8 years. This figure does not include the amounts paid by beneficiaries, who are responsible for paying 20 percent of the cost of this equipment.
CMS worked closely with committees of Congress, the Health and Human Services Office of the Inspector General, and the Government Accountability Office, which had reported on the problems in this area previously, to develop a comprehensive program to reduce fraud and abuse affecting PMDs. This program was unveiled in testimony before the Senate Finance Committee in April of 2004. The goals of this program are to ensure that beneficiaries have access to the appropriate technology to meet their needs, improve program oversight, and provide for more appropriate payments by Medicare.
Significantly, CMS has not limited its efforts to stopping fraud. The codes for billing this equipment incorporate industry standards of quality and durability. CMS has modified and strengthened the standards suppliers must meet in order to bill Medicare for PMDs, and is in the process of implementing a new accreditation program for suppliers to ensure that they will not only provide beneficiaries with high quality services but that they will comply with all Medicare requirements for providing this equipment and billing appropriately.
Additional actions taken by CMS to improve beneficiary access to appropriate mobility assistance include:
- A National Coverage Decision (NCD) on mobility assistive equipment that more closely ties the
Medicare coverage for a PMD to a beneficiary’s medical condition and ability to function in the home. The NCD was effective on May 5, 2005.
- Final regulations implementing provisions of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA 2003) which removed limitations on the types of practitioners that can order power scooters, and established the requirement that the treating practitioner conduct a face-to-face examination of the beneficiary and provide a written prescription for a PMD. These new regulations were effective on June 5, 2006.
- Quality standards for durable medical equipment (DME) suppliers, as required by the MMA 2003, to be applied by independent accreditation organizations to ensure that suppliers participating in Medicare are legitimate entities that maintain sound business practices and provide high quality items and services. In addition to the more general standards applicable to all suppliers, there are specific standards applicable to suppliers of PMDs. These standards were published on August 15, 2006.
- New billing codes describing the range of mobility technology currently on the market were released in June of 2006. These new codes are tied to industry standards of performance and durability, and are designed to support accurate payment and coverage decisions.
For more information, see the CMS website at: www.cms.hhs.gov/center/dme.asp.