Page 18 - Mobility Management, September/October 2021

ATP Series
Words Matter: The Language of CRT
were ever defined into the code. The code was never defined as aluminum; the code was never defined at all in terms of materials. It was only defined in terms of weight, and the weight is less than 30 lbs., which back in 1993, when the codes were created, that was probably the most inclusive for those kinds of chairs.
“But look at what’s out there now: Chairs that, depending on the configuration and what’s on it, are less than 20 lbs. That’s a huge difference. Also, the E1161 and the K0004 or the K0005 have no weight capacity assigned to them in the code require- ments. CMS is saying there is no weight limit. But yes, there is.”
Medicare now has no clear, practical path for a consumer to upgrade to a more costly titanium or carbon fiber ultralightweight chair, even if the consumer is willing to pay out of pocket. “The operational problem is that because [CMS has] said it’s included in the base price, now it’s considered unbundling if the supplier were to try to charge the patient the difference,” Stanley said. “The only way a supplier would be able to provide that really high-level, highly adjustable, super ultralightweight chair that the client needs would be to say, ‘I’m not going to do it as an assigned claim. You’re going to have to pay for the entire chair up front and wait for Medicare to reimburse you.’ Depending on the client, if they’re dual eligible, which a lot of our people are, then the supplier can’t do it non-assigned because [the client] has Medicaid. So we’ve got
this subset of people that are just Medicare, but also have enough money to pay out of pocket for an over-$3000 wheelchair and wait for Medicare to reimburse them. Only a handful of people are able to access the technology that they need.
“It’s a double whammy. When they were in that K0009 code, reimbursement was individual consideration. Medicare paid for what was actually provided. As soon as you moved it into a spec- ified code — then you had a fee schedule associated with it, and [CMS] said, ‘Oh by the way, all those special features? They’re included in the base price, you can’t bill for them.’”
Part of the problem, Stanley added, is a failure to understand the power that a code can have. “On the CMS side, when you
ask what are codes used for, their answer is ‘It’s merely a billing mechanism.’ It’s not meant to narrowly describe technology. And my answer from where I sit is, that would be lovely, except it is the foundation for coverage and payment. And when you have widely dissimilar products in the same HCPCS code, establishing a coverage policy that makes sense and determining payment that is adequate for access becomes impossible. That’s why I’ve spent so much of my career on HCPCS coding. Because as crazy as it is, it’s the foundation for everything that matters.”
And at least in some cases, the same could also be said of the language spoken every day in CRT. m
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