CMS PROPOSES NEW COVERAGE CRITERIA FOR WHEELCHAIRS, SCOOTERS
ANNOUNCES NEW, MORE SPECIFIC CODES FOR WHEELCHAIRS
In its continuing effort to improve Medicare coverage and payment for power wheelchairs and scooters, while protecting the Medicare program and taxpayers from abuse, the Centers for Medicare & Medicaid Services (CMS) today released draft coverage criteria for these devices, as well as new codes to ensure proper payment. These steps were outlined in our Modern Mobility Initiative announced last April.
“In taking these steps, we move closer to our goals of supporting appropriate prescribing, making accurate payment, and providing clear guidance to physicians and suppliers about power mobility devices,” said CMS Administrator Mark B. McClellan, M.D., Ph.D. “This will take us a long way toward bringing this important benefit into the 21st century. It also makes it clear that Medicare recognizes the importance of clinically-based coverage decisions.”
Medicare’s proposed coverage criteria would rely on clinical guidance for evaluating whether a beneficiary needs a device to assist with mobility, and if so, what type of device is needed. This new approach would replace an older, more rigid standard that relied on whether a patient was “nonambulatory” or “bed or chair confined.” The analysis begins with whether the beneficiary has a mobility limitation that prevents him or her from performing one or more mobility-related activities of daily living in the home. This evaluation includes consideration of whether or not an assistive device – whether a simple cane or a sophisticated power wheelchair or anything in between ‑ would improve the beneficiary’s ability to function within the home. The criteria also take into account any conditions, such as visual or mental impairment, that would affect the beneficiary’s ability to use the mobility equipment effectively.
“The proposed coverage criteria were developed with the intention of providing clear and consistent guidance to Medicare contractors and to clinicians to ensure that beneficiaries receive the type of mobility device that will provide clinical benefits,” said CMS Chief Medical Officer Sean Tunis, M.D., who spearheaded the agency’s move to a more functional assessment of mobility needs.
CMS plans to publish the final NCD in March and to provide guidance on how to use and document the new criteria.
CMS is also establishing new billing codes for power wheelchairs and scooters to assure that Medicare pays appropriately for these devices. To better reflect the range of power mobility products now available on the market, Medicare will expand the number of codes used for billing from 5 to 49. The more detailed coding will help facilitate getting the right products to patients and improve Medicare’s ability to pay suppliers appropriately.
“The technology, range of products, and market for power wheelchairs have changed substantially since the HCPCS codes for power wheelchairs were last revised in 1993,” said CMS Center for Medicare Management Director Herb Kuhn. “Currently, Medicare uses only one code, K0011, to pay for most power wheelchairs. Having more codes will permit us to more accurately reflect the different kinds of mobility products our beneficiaries are using.”
The new codes will incorporate “testing standards” in several areas (i.e., weight capacity, fatigue testing, speed and range testing). Accurate individual payment ceilings will also be developed for each of the new codes. The codes will go into effect on January 1, 2006.
CMS plans in the near future to publish a regulation implementing provisions in the Medicare Modernization Act affecting power mobility equipment. The regulation will remove the current requirement that only certain specialists can prescribe a power scooter. In addition, the regulation will require a face-to-face meeting between the prescribing professional and the beneficiary before a scooter or wheelchair can be ordered and delivered.
As mandated by the MMA, CMS is also developing quality and consumer standards for all suppliers of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS), as well as standards for specific product lines, including power mobility devices. These standards will implement strong quality controls for suppliers who play a key role in ensuring that a particular piece of equipment is appropriate for the individual beneficiary, and that it will be usable in the home setting. CMS intends to finalize these standards in the fall of this year and to implement them through an accreditation process conducted by one or more accreditation bodies to be designated at a later time.
The proposed National Coverage Decision will be posted on the CMS Website at www.cms.hhs.gov/coverage. Comments on the proposed NCD will be accepted until March 7, 2005. A description of the new billing codes for wheelchairs will be posted on the CMS Website at www.cms.hhs.gov/suppliers/dmepos.
CMS also plans to hold an Open Door Forum from 1 to 4 p.m. Eastern time on February 24 to allow for a dialogue with physicians, suppliers, and beneficiaries about the proposed NCD and to clarify the issues on which CMS is seeking comment. More information about how to participate will soon be posted at www.cms.hhs.gov/opendoor.