Page 17 - Mobility Management, March 2018

(E1230, K0010, K0011, K0012 and K0014) to 64 new HCPCS codes on Nov. 15, 2006. The bases were categorized into groups with similar performance characteristics, which allowed payors to establish reimbursement rates for ‘like products.’”
Stanley noted a similar skewing of payments when codes are rewritten to allow other products in.
As an example, she recalled that CMS “changed the descriptor for tilt in space, where the minimum requirement was equal to or greater than 40° of tilt. They decided they didn’t want to create
a new code for all the \[systems\] below 40°, so they changed the code descriptor to ‘20° or more.’ But you’re really talking about clinically different \[products\] when you’re talking about a chair that only tilts 20° and one that tilts 60°.”
With the tilt requirement altered, tilt systems that only tilted back slightly were suddenly in the same code as systems that offered far more tilt. Systems that tilted slightly, mostly for reasons related to comfort, were now grouped with systems designed to provide clinically bene cial weight shifting and pressure management for users unable to weight shift on their own. The fact that both types of tilt systems are in the same code implies that the systems are very similar in function and functional goals.
“Now, all this different technology ts inside this same HCPCS code,” Stanley said. “They didn’t change the pricing when they did it, so now your products that only go to 20° are in the same code as products that go 60°. So in that case, one could argue that Medicare is paying too much for the 20°, because the fee schedule was created based on the greater degrees of tilt.”
Code Changes Impede Bene ciary Access
Unfortunately, there’s no shortage of examples of inappropriate coding or grouping that harms consumer access to CRT.
“In complex rehab, the industry has identi ed numerous HCPCS codes that include very dissimilar products — from
very basic items of DME to highly con gurable items of complex rehab technology — because there is only one code to describe a large group of items,” Piriano said. “While CMS has the authority to expand the code set and establish new descriptions that more accurately de ne the critical and con gurable components indi- viduals with disabilities use in connection with their mobility base, they have not shown a willingness to do so.”
In reality, there’s evidence that coding changes have expanded, blurred and diluted product de nitions rather than more distinctly clarifying them.
“In 2003 there were unique HCPCS codes that de ned manual wheelchair handrims made of aluminum (K0061) or steel (K0060), ones that were plastic coated (K0059), handrims that had eight to 10 vertical or oblique projections (K0062) and ones that had 12 to 16 vertical or oblique projections (K0063),” Piriano said. “Unfortunately, on Jan. 1, 2005, the unique codes K0059, K0060 and K0061 were not only no longer separately billable when provided with a manual wheelchair — they were consol- idated into one HCPCS code (E2205), with the new description Manual Wheelchair Accessory, Handrim without Projections, Any Type, Replacement Only, Each. To further complicate the issue, when a clinically superior ergonomic handrim was developed and being brought to market, a unique HCPCS code was sought
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While the HCPCS system has a long history, Piriano said it only more recently became the law of the land.
“Initially, use of the codes was voluntary,” she said. “But
with the implementation of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), use of the HCPCS
for transactions involving health care information became mandatory.”
Rita Stanley is VP of Government Relations for Sunrise Medical. “While the basic intended use of the code set is for submitting a claim for payment,” she said, “Level II HCPCS codes serve as the foundation for coverage and payment for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). Fee schedules and coverage policies are created using HCPCS codes.”
Why “Any Type” Can Be Detrimental
Codes, however, have their limitations — especially when they’re seemingly expanded or stretched to include disparate products.
“Problems associated with HCPCS codes often stem from insuf cient code requirements or characteristics,” Stanley said. “Vague and overly broad code descriptors are the most recent cause for a HCPCS code to become a barrier to access. Revisions to HCPCS code descriptors for CRT products frequently include the words Any Type. Payment associated with these codes have often been established based on the initial code and the products it included, and the fee schedule is not recalculated to include the new technology being forced into that code.
“The result is that a product has an assigned code, but the reimbursement is insuf cient to allow access.”
Piriano agreed that the “Any Type” portion of a HCPCS code can be dangerous.
“When a code includes the words Any Type in the description, it gives rise to the inclusion
of a wide array of dissimilar products and inaccurate payments being made by
third-party payors,” she said. “CMS recognized this when they
expanded the ve power mobility device codes
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