Page 17 - Mobility Management, January 2019

Adjustable Cushion Codes
billed, but they cannot tell you anything about what was provided within that code. You have no way whatsoever of tracking outcomes for patients based
on the range of technology that’s within
a single code, and it creates enormous burdens to do research that would demonstrate the efficacy of certain prod- ucts for various patient populations. You can’t test one code to the next. You would literally have to test every single product against every [other] product inside the same HCPCS code. That’s unsustainable, and nobody could afford it in our industry because the industry is just too small.”
The Start of Adjustable
Cushion Codes
The adjustable seat cushion codes in use today were born from the best of inten- tions. In the early 2000s, Stanley said, CMS set out to create a set of seat cushion codes that would work better than the single code being used at that time.
“Dr. [Kenneth] Nelson and Dr. [Doran] Edwards had both put in a considerable amount of time looking at the products and thinking about how to verify that
the products were even effective, because there was no way to test them or measure them, or no requirement for testing,” Stanley said. “They had worked closely with RESNA on the standards regarding cushion testing, and part of the problem was the limited number and types of tests that were established for cushions. (See sidebar.) It takes a long time to develop product standards and test criteria, and for those to be accepted as ANSI RESNA requirements. It’s not something that
can be accomplished in six months. The process is very thoughtful, a lot of people serve on the standards committees, recommendations go through multiple rounds of comments and edits, and it’s a long and thoughtful process.”
The Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC), which preceded the PDAC, “had created an initial code set for wheelchair seats and set fee schedules for them,” Stanley said. “Because of the pricing methodology, it immediately took the higher-end, more
effective cushions — even those shown in evidence to be more effective — and threw them out of the realm of being able to be provided. And so there was a really fast, very loud outcry from the clinical commu- nity and the industry, as well as consumers. And CMS immediately responded. They recognized they had a problem.”
CMS, according to Stanley, also realized it had to develop a resolution quickly. Consumers were being provided with cushions during this period, of course, and those consumers could be stuck with ineffective cushions for quite some time, given the replacement policies in place.
“Unfortunately, there was not enough time to go back and say, ‘How do we resolve this? How do we create tests that can demonstrate what the true differences are in how these products function?’” Stanley noted. “Because functionality is just not built into the HCPCS code set.
“So they looked for technological differ- ences among the products in the problem- atic codes. Then a definition was created for adjustable, which was the ability to add or remove material after delivery and in the field. It provided an opportunity to get the more functional products moved out of the problematic codes, and [CMS] applied the [miscellaneous] K0108 code to those prod- ucts for a while until they had a chance to create new codes. But unfortunately, that new definition also moved over some prod- ucts that were not of the same caliber. The products in the adjustable skin protection and the adjustable skin protection and positioning codes are not equal.”
The initial intent was to provide a temporary solution until better-researched product distinctions could be identified. But that’s not what ultimately happened.
“At that time,” Stanley said, “there was talk of “Let’s do this now, let’s at least give this an immediate kind of resolution, and then we’ll start working with RESNA, we’ll work with some of the other research and academia folks, and we’ll try to figure out what the key differences are. What are the features of these products that make them distinct in terms of how they help treat and reduce skin injuries? When we have good tests that we can apply and
we have really good definitions, then we’ll create new codes for the adjustable [cushions]. Until then, this will be a good Band-Aid.”
But then the SADMERC contract ended and gave way to the new PDAC, and the plan to develop new codes for adjustable cushions never materialized.
“So if you fast forward to where we are right now,” Stanley said, “we have adjust- able skin protection and adjustable skin protection and positioning codes, but they’re still being defined as those products where you can add or remove material. And in the research about skin protection or
the ability to assist in healing wounds after they’ve occurred, there’s no evidence that says the most important thing is that you can add or remove material. There is a lot in the research that studies the material of the cushion itself, and when the material is a fluid, how that fluid reacts — not only how it works with the client just in sitting in their wheelchair, but as they move in their wheelchair, as they reach for objects, as they reposition, as they go about their day. There’s a real difference in how fluid reacts.”
The Impact of Current
Cushion Coding
The effect of the adjustable cushion codes’ broad inclusivity is far reaching. For instance, products within a single code are treated as comparable from a reimbursement standpoint, though in reality, the products within a code can be vastly different from each other in design, materials used, func- tional goals and clinical outcomes.
As a metaphor, Stanley said, “Let’s say you’re going shopping for a stove. You love to cook and bake, and you say, “I think I really want a Viking.” Well, if in the store it was ‘Oven, any type,’ and the store took all the ovens they carried and arranged them in descending order based on price and picked the middle number and said, ‘Here’s what an oven in our store costs, whether you’re buying a toaster oven or you’re buying a Viking oven,’ how many people do you think they’re going to let walk out of their store with a $10,000 Viking at $1,000? And how many people do you think are going to appreciate
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