The coverage criteria draft eliminates the requirement that beneficiaries must be bed- or chair-confined to qualify for a wheelchair, but keeps intact Medicare's rule that limits coverage to DME primarily used in the home. CMS is accepting public comment on the draft until March 7.

At the same time, Medicare has introduced 49 new codes for power chairs and scooters, breaking the broad K0011 code down to specific chair configurations.

"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 McClellan, adding that the new coverage criteria "makes it clear that Medicare recognizes the importance of clinically based coverage decisions."

Coverage Criteria
The draft National Coverage Determination (NCD) announced last week spells out factors that qualify Medicare beneficiaries for mobility equipment, from walkers to manual wheelchairs to scooters to power wheelchairs. It closely follows recommendations from the government's Interagency Wheelchair Work Group, a panel of clinicians from several federal agencies.

Stakeholders have praised the NCD's function-based determination of medical necessity, saying it is a vast improvement over current coverage criteria. But the in-the-home rule remains a sticking point. CMS explained that "an NCD would not be the appropriate mechanism to change that rule."

"We were very disappointed that they failed to address the in-the-home restrictions, but it's what we expected," said Barbara Crane, a physical therapist who co-chairs the Clinician Task Force, a group that has submitted coverage policy recommendations to CMS.

Some have said that because the in-the-home rule is part of Medicare law, it may take an act of Congress to change it. Others have said CMS could change its interpretation of the law, which they say was written to define services outside of institutions, and not only within the beneficiary's home.

Crane added that the NCD released last week left "several outstanding issues for which they failed to provide clarification." For example, she said that coverage criteria requires mobility equipment to substantially improve activities of daily living, adding that the language did not make clear whether CMS will consider mobility itself as an "activity of daily living." If not, a paralyzed quadriplegic who cannot perform any activities of daily living could technically be denied a wheelchair. "The vague language makes it difficult for clinicians and suppliers to figure out how the DMERCs are going to interpret it," she said.

In March, CMS plans to publish the final NCD and to provide guidance on how to use and document the new criteria.

Coding
CMS has organized the 49 new power chair codes into a plethora of groups and subgroups, dividing them into specific power chair configurations. All will go into effect Jan. 1, 2006, while existing power chair codes--K0010, K0011, K0012, K0014--will be discontinued with no grace period or crosswalks. Codes include those that will be used not only by Medicare but by Medicaid and private insurers as well, sources said.

"I think [CMS and the SADMERC] have done a yeoman's job in putting this thing together," said Simon Margolis, vice president of clinical and professional development for Chattanooga, Tenn.-based National Seating and Mobility. "On the surface it looks like a coherent, complete document. Problem is, when you work so hard on a document, you don't see some of the warts."

Those "warts," he explained, include minor glitches--an overlap between pediatric and adult chair specifications, for example. But overall, the codes "follow a reasonably sound formula," he said, adding that the industry should be able to work with the government through the problems.

The final codes feature a basic equipment package that has some fearing allowables will not account for all costs. But because CMS names specific requirements for what components make up a basic equipment package, fees should account for costs of the components, according to Tom Rolick, vice president of business development for Lebanon, Tenn.-based Permobil. "With all the items they put into a basic equipment package, they will have to consider the costs of each item so the fees are appropriate," he said.

Before the codes take effect, the SADMERC will need to test every model of power chair and scooter available and assign each to a code. CMS will then assign fees. "It will be challenging for manufacturers to identify the configurations that align with the codes," Rolick explained. "The SADMERC has got their hands full now."

But the process may be less harrowing now that CMS has pushed back the implementation deadline to next year, sources said. The agency originally planned to make the codes effective July 1.

"This is a phenomenal body of work that needs some small tweaking to create a situation where the industry is 100 percent better off than it was before," Margolis said. "We'll look back and say, 'How did we ever live with those K0011s?'"

Putting the Pieces Together
According to sources, CMS will soon start the most challenging part of revamping the mobility benefit---piecing all the elements of the mobility puzzle together. These include developing specific documentation requirements from the coverage criteria and matching codes to available technology, along with educating stakeholders about the new system.

In a future regulation, the agency also plans to remove the current requirement that only certain specialists can prescribe a scooter. The regulation will also require a face-to-face exam with a physician prescribing the mobility equipment. And according to industry sources, a new wheelchair CMN also is under consideration.

"This is only the first part of a significant process," Margolis concluded. "I'm not at all upset about 49 new codes. I think more codes the better to describe the technology. The difficulty [will be] educating the suppliers and manufacturers, and educating the DMERC and CMS staff about how to handle this stuff when they bill it."

CMS will hold an Open Door Forum on Feb. 24 from 1 to 4 p.m. Eastern Time to discuss the changes. More information will be posted soon at www.cms.hhs.gov/opendoor.

To view the NCD and make comments, visit the CMS Web site by clicking here. New codes are also available in the "highlights" section of the agency's DMEPOS home page, at www.cms.hhs.gov/suppliers/dmepos/.