Page 18 - Mobility Management, January 2019

ATP Series
Adjustable Cushion Codes
paying $1,000 for a toaster oven? A toaster oven is great if all you’re doing is toasting bread. But if you’re making homemade bread and you need to proof it and have it rise and all the things that have to happen to produce artisan bread, then you’re going to want to invest in that oven.
“And that example isn’t about medical need. HCPCS codes allow or deny access to medically necessary technology. What [CMS] has done is not only have they said, “We’re taking prod- ucts with totally different functions, totally different technology intended for a totally different population of people, and we’re going to put them into one single code with one single payment amount,” but also, “Oh by the way, you can’t even do a patient upgrade because these technologies are in the same HCPCS code, and upgrades within the same HCPCS codes are not allowed.
So in this situation, consumers can’t obtain the needed item unless the supplier provides it non-assigned, the consumer pays for it out of pocket, and then is reimbursed by Medicare [at] 80 percent of the allowed amount. CMS has created a scenario that has made access very challenging and only for those beneficiaries who can afford to pay out of their own pocket.”
A wheelchair user’s inability to obtain the cushion that offers the best clinical outcomes can be dire.
“Unfortunately, when a cushion fails for an individual, the implications and consequences are significant,” Stanley noted. “Once you have skin injury, whether it’s healed or how long it’s healed, you are now at a much higher risk than if you had not had that skin injury. So the impact of that, financially — because of the expense of healing wounds — and also the pain and suffering of the consumer, are fairly easy to measure. This is [a product group] that should be easily measurable if they would allow somebody to go through and do what we did years ago, which is to bring the technical experts to the HCPCS coding people and have collabora- tion that says, ‘We’re all after the same thing here.’”
Technology & HCPCS Code Creation
While payors might view HCPCS codes largely or solely from a number-on-a-claim perspective, product development and design are deeply impacted by code definitions.
“There are literally hundreds of examples where the CMS work group has gone back in, after a manufacturer has submitted for a code application, and made a decision to change the code descriptor to say ‘Any type’ so more and more technology could get shoved into a single HCPCS code,” Stanley said. “A more recent strategy is to say, ‘All of that is included in the base price
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of the wheelchair, so we’re going to change the code descriptor to Replacement only. You can only bill for it when you go to replace it.’ “You can no longer bill for it at initial issue. That includes any
special handrims, dynamic backs, or [Sunrise Medical’s] mono back. There are some really innovative technologies [about which] CMS has said, ‘That’s already included in the base price of the wheelchair.’” This [technology] didn’t even exist when they created the wheelchair codes or developed the fee schedules. How could it be included in the base price? But that’s the kind of decision that’s been coming out of that work group for the last decade.”
That funding environment — where innovative products with new functionalities are lumped together with older, less effec- tive products in the same code with the same allowable — can discourage manufacturers from developing products that could result in better patient outcomes. Research and development is expensive; why bother if the manufacturer will end up losing money on those resulting products because allowables are still being based on older, less functional technology?
From a profitability standpoint, the alternative is for manufac- turers to make products that fit existing code requirements and are less expensive to produce. But that removes any motivation for manufacturers to be innovative with new product designs that could improve patient outcomes and their quality of life.
“HCPCS codes need to be based on technological differ- ence and functional difference,” Stanley suggested. “Not that [a manufacturer] can just claim [their] product is better and somehow get a different code. But if I can demonstrate that my product is different in material, technology or design, and
All stakeholders win in a scenario where HCPCS codes are established based on technological and functional differences and their benefits to consumers — Rita Stanley
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