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New Medicare Power Wheelchair, Scooter Coverage
Criteria Criticized
Medicare Rights Center says CMS remains in the Dark
Ages
Feb. 5, 2005 – Medicare this week released draft
coverage criteria for coverage of power wheelchairs and scooters, which
they say will rely on clinical guidance for determining need. But, the
Medicare Rights Center says the new policy
“does nothing to provide mobility to people who need help to get out of
their homes.”
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.”
“CMS remains in the Dark Ages by proposing to
retain an inhumane coverage policy that leaves people with disabilities
isolated in their homes and walled off from their communities,” says
Robert Hayes, president of the Medicare Rights Center. “The practice is
a continuing affront to the policies of both Presidents George H.W. Bush
and George W. Bush who, respectively, championed the Americans with
Disabilities Act and the New Freedom Initiative. These steps, unlike the
CMS policy, were aimed at liberating people with disabilities from
isolation and dependence.”
“We do applaud some aspects of the proposed
wheelchair coverage policy: the function-based determination of medical
necessity and the effort to develop new codes for paying wheelchair
suppliers” added Hayes.
But he wants the White House to review the new
policy. “The President has a special moral
obligation to lead Americans to independence, and his federal agencies
should not be permitted to continue policies that breed isolation and
dependence,” he said.
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The new 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.
The Centers for Medicare & Medicaid Services (CMS)
also released new codes to ensure proper payment. These plans were
outlined in the Modern Mobility Initiative announced last April.
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.
“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.”
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.
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