CMS Revises Fee Schedules; Implementation Date Hits This Week
The Centers for Medicare and Medicaid Services (CMS) revised its fee schedule for power mobility devices late last week, just before the upcoming implementation date of Nov. 15 hits this week.
The new allowables for both scooters and power chairs indicate increases for Group 3 power chairs but decreases for some Group 1 and 2 products. Initial industry reaction is mixed.
DuWayne Kramer, CEO of PaceSaver/Leisure-Lift, Kansas City, Kan., says, "From my standpoint, CMS significantly reduced a whole bunch of power wheelchair codes. There were significant reductions in a lot of categories, such as bariatrics. Even products where they raised prices, those prices still aren't at market value."
"I saw drops of 25 percent in some categories and those are the bulk of what CMS are going to be paying for. I was calling it Black Friday," Kramer says.
Commenting on the revised fee schedule, Mark Sullivan, vice president of rehab at Invacare, Elyria, Ohio, says, "At the end of the day, it's still a 10-percent cut, which is problematic. But certainly, we are very pleased with the hard work and the fact that CMS really responded to try to help some of the folks in Group 3 continue to get appropriate equipment."
CMS used the Aug. 23 classification list its most current database of manufacturer applications, test results and attestation to refine the new fee schedule. According to CMS, the key data used to compute the revised fees (in summary) includes:
- Questionable PMD test results produced off shore are now eliminated from calculations.
- Data submissions by manufacturers that are merely under development and not yet being produced are not included in the pricing database.
- Undocumented test results and imcomplete applications submitted without attestation are excluded.
- The new coding set bundled certain basic equipment requirements into the codes based on the clinical needs of beneficiaries.
- CMS revised the formula to more accurately reflect the year of submission of the MRSP data.
- CMS ensured inflation of the data from the base year for the fee schedule to the present was based on uniformly applied inflation factors reflecting the updates mandated by Congress.
- CMS also ensured that anomolies in pricing that resulted from a lack of data for certain codes were corrected using data for comparable products.
- CMS withdrew fees for Group 4 (high activity) and Group 5(pediatric) PMDs from the fee schedule since these are items that would rarely be covered by Medicare.
Kramer expressed concern that many products are not being categorized accurately and therefore CMS is using flawed data to determine pricing. "I don't think the people there know what they are doing, and when they base pricing on it and when 50 percent of the categorizing is wrong, it gets all messed up," Kramer says.
"We are going to start the appeals process today," Kramer says, "because units are in the wrong category."
Two weeks prior to the implementation date, CMS revised the wording of the local coverage determination (LCD). The "stand and pivot transfer" wording in the LCD was completely removed, and the number of power mobility devices that are eligible for advance determination for Medicare coverage was expanded.
Under the revised LCD, to qualify for a Group 3 power wheelchair, the requirement states that the beneficiary's mobility limitation "must be due to a neurological condition, myopathy or congenital skeletal deformity." The revised policy accounts for people with progressive conditions such as multiple sclerosis (MS).
"So overall, we are pleased with the response we have gotten from them on both the LCD and the fee schedules," Sullivan says. "They really worked with us, so we are really happy about that. We still think there's work to do on the calculation, and we want to keep working with them to do that. Just in general, the whole gap-filling methodology (CMS is) working on new methods, and we want to be a part of that. We are still suffering somewhat from two years ago, when they used gap-filling on (wheelchair) cushions, which suffered a 30- to 40-percent reduction. And then you have manual wheelchairs coming up. There are still a few glitches on the power side of this. We are not complaining; we are thrilled that they worked with us. But we want to continue to work with them to come up with a fair method of calculating fee schedules for our industry."
For a list of the new allowables, visit www.cms.hhs.gov/DMEPOSFeeSched/01a_Power_Mobility_Devices.asp.
This article originally appeared in the November 2006 issue of HME Business.