Page 24 - Mobility Management, March 2018

Funding Series
Coding & Ef cacy
Coding & the Separate Bene t Category Continued from page 20
list compared to the massive number of straps, the list’s “middle” product wasn’t a foot box; it was a strap. The price of that strap was used to calculate the reimburs- able amount for a CRT foot box that’s much more fully functional — and much more costly to produce.
“They use the median product,” Stanley said of how CMS chose the
price to work with. “So it doesn’t have anything to do with the amount \[the product costs\]. If you list them all, highest to lowest, and pick the middle \[product\] from the list, the odds of any of our CRT items ever being the median product is almost zero. Then \[CMS\] de ates it using the current de ation rate, and then they rein ate it back to today with at least
10 years of CPI \[Consumer Price Index\] freeze. So when you take an item and cut it to less than half, and it’s already an item that’s substantially below the retail of any of the higher-end, more fully featured functional products, and then you
can’t even rein ate it to current day — you’re toast.”
Compare that current scenario with one that could take place once the separate bene t category is in place. Foot boxes could have their own code, and the code would contain not heel loops or leg straps, but only foot boxes.
Since foot boxes are products used only in CRT — because typical DME wheelchair users don’t need them — the new code would contain only foot boxes made by CRT manufacturers. While manufacturers’ foot boxes would vary slightly in price, “it’s not thousands or hundreds of dollars,” Stanley said. Pricing among the foot boxes would be similar enough that if CMS listed the products and chose the “median” foot box, the resulting allowable shouldn’t put it out of a client’s nancial reach. Access
to CRT wouldn’t be routinely threatened the way it is today when CRT products are inaccurately grouped with DME ones.
And CRT manufacturers would be able
to innovate and develop new, more fully featured products for consumers with severe disabilities without worrying about having to compete, pricing wise, with standard DME.
Of current coding policies, Stanley said, “\[CMS\] puts barriers in place that make a manufacturer say, ‘It’s too much risk. I’m going to make a foot box and they’re going to price it as a toe loop/heel loop/leg strap, and I can’t do it. I’m going to spend all this money to develop a product and bring it to market to nd out I can’t get a code, I can’t get payment, I can’t get coverage.”
That dilemma is ultimately suffered
by the consumer, who ends up with less functional equipment and loses the ability to live more independently.
“There’s equipment that might
help them do that,” Stanley said, “but \[consumers\] are being denied access to it, whether it’s intentional or unintentional. It’s occurring because of the coding and payment structure.” m
Look at those rigid chairs versus a Quickie 2, where everything can be moved or adjusted, or it’s modular because you’re taking the person from the beginning phase of a disability all the way through as they morph and change, learn and grow, lose weight, gain weight. When you have a folding chair that’s modular, you have the ability to adapt as the person progresses or their disease progresses or they change.
“Then you get a person who’s been in a chair for a long
time. They know exactly how they want to sit; they don’t want anything extra that’s going to come loose. And yet we have one code — K0005. But you’ve got a K0001, a K0002, a K0003, a K0004, a K0006, a K0007 that are all standard \[wheelchair codes\], for chairs that come in two basic sizes, no adjustability. There are all those codes for \[standard chairs\], but we have one.”
Ideally, Stanley suggested there could be different codes in the future to distinguish a rigid ultralightweight chair being ordered by a knowledgeable client with paraplegia who’s already had
four previous chairs, and a newly injured client who’s just moved from the rehab hospital back to his parents’ home, is now gaining a little weight from Mom’s cooking, and is still learning how to transfer. Perhaps the catch-all K0005 code could spin off a new code for adjustable, folding ultralightweight chairs.
“We may even see a range that says if you’re talking about a folding chair that is for the new user, there may be all kinds of requirements in terms of adjustability and options and features,
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because you can’t really address the needs of that newly injured person if you don’t have some of that capability built in,” Stanley suggested. “And then you may see something different for people who just need \[a chair\] that’s between what today is a K0004 and a K0005. And then you want that individually con gured and manufactured chair to meet the measurements of a speci c person — when you’re getting into I want x degrees of bend on the front end, I want a taper on the front end, I want a certain back-angle degree, I want this much squeeze.
“If you look at the bucket today of what’s classi ed as a K0005, the only requirement is that it weighs less than 30 lbs., it has a lifetime warranty, you have to be able to adjust the rear wheels. It doesn’t say how you have to adjust them, or how far you have to adjust them. Do you have to adjust them vertically? Horizontally? Both? It’s not de ned. So on the PDAC Web
site, you’ll see chairs in there that have very little adjustability and just barely are under the 30-lb. mark, and then you’ll see chairs in there that weigh 17 lbs. and have a massive amount of adjustability.”
A separate bene t category could go a long way toward nally acknowledging the very precise, highly individualized measure- ments, adjustments and options that de ne CRT.
“Congress gets it,” Stanley said. “And I think that’s why we have the amount of support that we do for the separate bene t category now.” m
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