Page 20 - Mobility Management, March 2018

Funding Series
Coding & Ef cacy
to accurately describe the technology. Instead of allowing a new HCPCS code
to be added, CMS expanded the E2205 code description, effective Jan. 1, 2008, to include handrims that are ‘ergonomic or contoured’ as well.”
Stanley vividly remembered those handrim code changes. “\[CMS\] changed it to say Any type, including,” she said. “They literally added the name of the product
to say, ‘Stop submitting HCPCS code requests. This is where your product goes.’
“But then they added ‘replacement only’ to the end of the descriptor, so now you can no longer bill for any type of handrim on initial issue.”
And Stanley remembered another example of impeded access.
“Another scenario is when we applied for the code for shoe holders and ankle huggers. And CMS said, ‘Looks like a toe loop/heel loop to me.’
“First of all, neither of those products looks anything like a toe loop or heel loop, and it wouldn’t take a huge leap, I don’t think, for most people to understand that
a little webbed strap is far different from
a manufacturing perspective than a shoe holder. But what \[CMS\] said was, ‘We’re going to say Toe loop/holder, any type,’ and just expanded it so nearly anything could go in the code. They did not recalculate
the fee schedule, so that fee schedule was based strictly on toe loop technology replacement, essentially, probably based on supplier-submitted charges from the ’80s.”
From that example, Stanley said, “you can begin to see: I’ve got pricing that, when it was created, had nothing to do with this now-expanded de nition of new technology that’s going into it.”
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Ankle huggers and ergonomic or high-performance handrims are just
the beginning. Stanley pointed out the current coding for headrests, compared to the headrest coding that had been used as recently as 2004:
In 2004: E0955 — Wheelchair acces- sory, headrest, cushioned, pre-fabricated, including xed mounting hardware, each.
From 2005-present: E0955 — Wheelchair accessory, headrest, cush- ioned, any type, including xed mounting hardware, each.
“There are many examples of codes that contain CRT products where the technol- ogies within the code vary in meaningful
ways,” Stanley noted. “The products vary in features and function, clinical appli- cation, and costs to manufacture and provide. These products are not inter- changeable to meet the medical needs of individuals.”
The Costs to Consumers
Ultimately, when HCPCS codes become bloated with dissimilar products thanks to descriptions that are stretched to accommodate more and more items, the consumer loses.
The danger is especially real and critical for CRT clients, who have very speci c and complicated clinical needs and who need custom- t or customized seating and mobility equipment.
But Piriano pointed out that such code scenarios can also be bad for payors.
“Clinically appropriate assistive tech- nologies that meet the identi ed needs of an individual with disabilities are essential to their health, safety and well-being,” she said. “However, very basic to very complex
items comprising the same HCPCS code, with one fee schedule, results in inaccu- rate reimbursement on both ends of the product spectrum.
“Basic items of DME are reimbursed at a high rate that makes them very pro table, which could entice providers to put pro t over people. Conversely, highly con gu- rable and complex rehab items that may have additional features or are made from technologically advanced materials are costlier, but reimbursed at an insuf - cient rate. This makes it very dif cult
for complex rehab companies to pay the manufacturer for the product and pay
for the professional skills of the RESNA- certi ed Assistive Technology Professional (ATP) who is directly involved in the provision of the equipment. Clearly, with inadequate resources to provide necessary CRT products, the welfare of individuals with disabilities may be compromised.”
She added that imprecise HCPCS coding also makes it dif cult to track the speci c types of equipment being used.
“A lack of appropriate HCPCS codes to de ne the technologies provided for people with disabilities does not allow CMS or any other third-party payor to accurately capture the true utilization of these items. The risk is that there is, or will be, a misperception that these items are not used, or needed, further complicating access.”
Stanley said she’s been advised that if a CRT provider deems a Medicare allowable too low, the provider can handle the claim as a non-assigned one. She’s aware of that option, but rejects it as impractical.
“You can do that,” she said, “except if it’s a Medicaid person or a dual-eligible person, which is the highest percentage of people with disabilities, you’re not allowed to do non-assigned claims. And you can’t even do an ABN (Advance Bene ciary Notice of Non-Coverage) with them. So that means no access.”
The Costs to CRT
In addition to decreased access to life-changing CRT for consumers,
When a code includes the words “Any Type” in the description, it gives rise to the inclusion of a wide array of dissimilar products — Julie Piriano
MobilityMgmt.com