Page 22 - Mobility Management, March 2018

Funding Series
Coding & Ef cacy
How a Separate Bene t Category Could Help CRT Codes
The complex rehab technology (CRT) industry has been working toward establishing a separate Medicare bene t category for seating and wheeled mobility equipment used by people with severe, permanent and sometimes progressive mobility-related conditions.
Would establishing a separate Medicare bene t for CRT — one distinct from
the durable medical equipment (DME) bene t — help with CRT’s ongoing coding problems?
Rita Stanley, VP of government relations for Sunrise Medical, says yes.
The Needs of the 8 Million
The difference between Medicare bene- ciaries who use CRT and those who use DME is at the heart of why the separate bene t category is needed, Stanley explained.
“The genesis of the separate bene t category,” she said, “was the realiza-
tion that as long as all of the policies
that Medicare is developing — coding, coverage, payment — are really geared toward the 80 percent of the Medicare population people — toward the 48 million versus the 8 million \[who use CRT\] —
then we’re always going to be in this
vicious cycle. Because when you write policy centered around aging, frail, acute illness kinds of things, you’re not writing policies that are particularly friendly toward people with permanent disabilities. And that’s where we’ve constantly had this battle. Our people are different.”
Stanley pointed out that distinguishing bene ciaries who use Medicare because they’re seniors from bene ciaries who use Medicare due to disability could also bene t the agency.
“So with the separate bene t category, we’re saying, ‘This is good for you, too, Medicare, because now you’ve got a solid line that says your 48 million people that are over 65 sit in that bucket and they use DME, and you can write all your policies around that population of people.”
Bene ciaries who use Medicare because they have serious disabilities have different needs and goals, Stanley said.
“Our population of people on the \[CRT\] side of the line are people that may be over 65, but they also might be 35 or 40, and they’re eligible purely based on their disability,” she said. “And those people are going to have a whole separate set of codes, coverage and payment policies that speci cally support their medical needs and functional needs. It addresses the coding issue, the payment issue, equip- ment and long-term care.”
Creating a separate bene t category for CRT would also remove CRT users from Medicare’s controversial policy of only considering bene ciaries’ needs within their homes, not outside of it.
“\[The separate bene t\] addresses the in-the-home problem,” Stanley said. “You don’t tell a 35-year-old person who’s trying to take care of children or trying
to work, ‘I’m only going to provide you equipment that gets around inside your home.’ You make sure they have access to the community as well.”
Starting with a Blank Slate
Stanley said the language in separate bene t category bills that have been put before Congress is very speci c.
“It’s very clear what Congress’s intent is,” she said. “The intent is to have policies that treat the population of people with disabilities in an appropriate manner. And it wipes the slate clean. It doesn’t say we’re going to continue to put Band-Aids on top of a broken process. It says, ‘We’re going to pull these people out, we’re going to pull this \[CRT\] equipment out, and we’re going to put safeguards in place that say only the people that really know what they’re doing can even address the equip- ment needs of this population.”
The new bene t category would have its own HCPCS codes, and the accompa- nying de nitions and descriptions would at last compare similar CRT products, rather than lumping those products with DME products that have signi cantly different applications.
When products intended for CRT clients are grouped, coded and priced together with much less fully functional DME products (see the foot box sidebar), Stanley pointed out that the resulting allowables often put CRT items nancially out of reach.
“If you look at the population of people with complex disabilities that need CRT, that population is \[so small\] in compar- ison to general Medicare,” she said. “So the array of products available that are standard, basic products — there’s a ton of them.”
Stanley said that when she collected pricing data for CRT foot boxes, she found a handful of manufacturers who produced them. There were only a few CRT foot boxes available compared to the litany of DME positioning straps that were in the same code as the foot boxes.
That’s problematic because of how CMS calculates allowables. Stanley said the agency listed all of the products within
the code, from the highest priced item to the lowest, then chose the product that literally sat in the middle of the list. That product’s price was used as the basis to begin calculating the allowable.
Because there were so few foot
boxes on the
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