Grassroots Mobility

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June 2005

By Laura Cohen, PhD, PT, ATP, and Barbara Crane, PhD, PT, ATP

The Clinician Task Force is working to change CMS wheelchair policies

As physical therapists with 18 and 16 years of clinical practice experience, respectively, and recent graduates of the Health and Rehabilitation Sciences doctoral program at the University of Pittsburgh, we embarked on our journey into Medicare wheelchair coverage policy at a stakeholders meeting in Chicago in May 2004. We had very little understanding of the magnitude or importance of the task we were about to undertake. We both had knowledge of the implications of the national coverage policy on our patients based on past experience completing the requisite Certificate of Medical Necessity (CMN), which answers questions that have long been the basis of wheelchair coverage for Medicare beneficiaries since 1965.

On a daily basis, clinicians are tasked with interpreting these questions, answering them in a way that facilitates coverage, and balancing the clinical needs of the patients they serve within the limitations of this very antiquated policy. Per clinical-practice standards, clinicians must focus on all of the mobility needs of patients to allow maximum function and independence. The Medicare wheeled mobility device policy requires that clinicians either ignore some of their patients' needs or risk noncoverage of clinically appropriate equipment.

Our clinical experience did little to prepare us for our journey into the world of public policy. With the guidance and assistance of many others much more familiar with policy issues and processes, we dove right in and became the co-coordinators of the Coalition to Modernize Medicare Coverage of Mobility Products (CMMCMP), Clinician Task Force (CTF). Along with 30 other seating and mobility clinicians from across the United States, we organized to provide clinical guidance and input to the Centers for Medicare and Medicaid Services (CMS). The CTF's ultimate goal is to influence policy change to allow appropriate access to wheelchair technologies for those who have legitimate medical and functional—in other words, clinical—needs.

Barbara Crane

This has been an educational experience for everyone involved. Above all, we have learned that clinicians can and must provide input into public policy that directly impacts clinical practice. Otherwise, practice is dictated by deficient policy that not only interferes with contemporary professional practice but also ultimately restricts access to services and technologies for those we serve. Following is a summary of our work and our experiences to date.

HOW DID WE GET HERE?
The National Coverage Determination (NCD) for wheelchairs was originally drafted and interpreted in 1965. This coverage policy reflects both the wheelchair technology and level of clinical practice in existence at that time. However, both clinical practices and wheelchair technologies have progressed dramatically during the past four decades. Clinicians specializing in the recommendation of wheelchairs for individuals with ambulatory disabilities have struggled for years with the "bed or chair confined" standard that is currently the basis for coverage of wheelchairs.

This conflict stems from a mismatch between standard clinical practice and a restrictive wheeled mobility coverage policy that is inconsistent with other public policies such as the Americans with Disabilities Act, Ticket to Work, and the Freedom Initiative. Additionally, current wheelchair technology—particularly powered mobility technology—is no longer adequately described by this antiquated coverage policy, and the CMN does not collect sufficient information to make clinical determinations of medical necessity or appropriateness for the wider range of equipment available to individuals who use wheelchairs. Hence, it is not surprising to us that the current process is fraught with problems, which often result in waste and abuse.

WHAT IS INVOLVED?

Laura Cohen

Coverage of wheeled mobility devices (manual wheelchairs; powered wheelchairs; and power-operated vehicles or scooters) is provided to Medicare beneficiaries under the voluntary, outpatient-based Part B of the Medicare benefit, and it falls under the category of Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS). The three most important determinations that will impact access to any item of DMEPOS are coding, coverage, and payment.

While CMS, specifically, the Center for Medicare Management, has ultimate authority for each of these determinations, its contractors, the four regional Durable Medical Equipment Regional Carriers (DMERCs), and the Statistical Analysis Durable Medical Equipment Regional Carrier (SADMERC) are responsible for specific policy development. Within the area of coverage for wheeled mobility, there is the NCD, which currently contains the "bed or chair confined" language, and the Local Medical Review Policy (LMRP), which contains detailed rules outlining coverage for the individual codes and other coverage restrictions.

The remaining key influences are coding of wheelchairs and their accessories in the Healthcare Common Procedure Coding System (HCPCS), and payment policies, which assign payment category—such as purchase or rental—and, of course, the payment amount for specific HCPCS codes. Other items that can influence access to technology are coverage policies and payment levels for services, which are provided by medical professionals and billed using Common Procedural Terminology (CPT) codes.

THE CMMCMP CLINICIAN TASK FORCE
In December 2003, out of concern for the increased utilization of wheeled mobility devices, the four DMERC medical directors released a Medicare coverage policy clarification statement. This clarification statement indicated that if a person was able to take a few steps, he or she would be considered ambulatory and ineligible for a wheeled mobility device.

Prior to this clarification, clinicians typically considered whether a Medicare patient was "functionally ambulatory" when determining the need for a wheeled mobility device. This new clarification prevented clinicians from determining whether a patient was truly "ambulatory" according to clinical evaluation and imposed a different standard contrary to contemporary clinical practice. While this clarification was quickly retracted, it became apparent to many clinicians that the Medicare policy needed to be revised to prevent this type of clarification from severely restricting access to appropriate wheeled mobility devices.

In an attempt to involve more clinicians in the process of changing the Medicare policy, the CMMCMP CTF was formed in May 2004 to draft a formal request to CMS for the reconsideration of the current Wheeled Mobility Device National Coverage Policy. Major limitations of the Medicare policy identified by clinicians were the use of the "bed or chair confined" standard for eligibility and the restriction of access to devices that would be useful only within the home. On June 14, 2004, CMS held an open-door forum and organized an Interagency Wheelchair Work Group (IWWG), comprised of federal employees who were tasked with drafting a revised wheelchair coverage policy, which negated the need for a reconsideration request.

At that time, the IWWG requested specific clinical guidance. The CMMCMP CTF submitted a proposal to CMS and the IWWG outlining an objective and consistent process by which medical necessity for wheeled mobility may be determined and documented.

Since the extremely restrictive Medicare coverage policy clarification was issued in December 2003, several important milestones in the evolution of a new Medicare wheeled mobility device coverage policy have been achieved. CMS has held numerous public meetings to gain input. Concurrent with the development of a new NCD determination, CMS has been developing new coding and payment policy, and new documentation requirements.

DMERC medical directors will be writing a new LMRP based on the released NCD determination. Drafting of a new CMN and new coding guidelines by the SADMERC has begun. The CTF is hopeful that the developments in all aspects of Medicare wheeled mobility device coverage policy will result in appropriate access to wheeled mobility devices for Medicare beneficiaries with functional mobility impairments.

AFFECTING THE PROCESS
To make meaningful changes that are in the best interest of clients and the medical profession, clinicians need to get involved. With our increasing involvement in this process through the CTF, it has become apparent that clinicians are critical contributors to this process. Knowledgeable and experienced clinicians know the variety of needs of the patients we serve. Many critical policy decisions that are being considered have clinical implications for our patients and our clinical practice.

Policy-makers and their traditional advisers often have no direct experience in this highly specialized area of clinical practice. Policy-makers are also averse to relying on either equipment manufacturers or equipment providers for much of the information that is critical for drafting coherent policies, yet they often have limited access to alternative sources of information. Clinicians practicing in the area of wheelchair service delivery have the widest exposure to patients with a variety of needs and abilities. With even more input from clinicians, we hope to have the ability to shape the development of a NCD determination and LMRP that truly meets our patients' clinical needs.

Our experience with the processes that we have been involved in to date has been positive overall. Participation in this process has afforded us a level of professional respect and value based on our knowledge and experience in this field. We foresee that these positive relationships will continue to expand and that we will be called on for advice in other coverage policy areas.

GETTING INVOLVED
There are many ways to get involved and influence policy. First, get informed and educated by getting involved with professional organizations. Working with a group such as the CTF is only one opportunity among many. Clinicians also need to monitor the activities of their respective professional organizations. These organizations, such as the Rehabilitation Engineering and Assistive Technology Society of North America (RESNA), American Physical Therapy Association (APTA), American Occupational Therapy Association (AOTA), American Speech-Language-Hearing Association (ASHA), and National Registry of Rehabilitation Technology Suppliers (NRRTS), have specific activities related to governmental affairs.

Professional organizations have a responsibility to respond to their members. So, if you are a member of a professional organization, contact the organization to make sure that they know you have a vested interest in CMS policies related to wheelchairs and that the changes in coverage policy have a direct effect on you as a clinician. Follow new coverage proposals, and work through professional organizations to submit written comments. Additionally, if time allows, there are often public meetings where individuals are allowed to provide comment. Sign up for key list servers through the CMS Web site that will provide you with contemporary information in your areas of interest.

Also, get involved through the political process. Contact key Congressional members who represent you, and make sure they hear your viewpoint and understand the importance of these issues for their constituents. Invite policy-makers into your clinic. Show them rehabilitation technology devices, what is involved in the evaluation and recommendation process, and the impact the appropriate mobility devices have on individuals with mobility needs.

Finally, spread the word. Inform consumers and other stakeholders about the issues and actions they may take to get involved. Introduce them to advocacy groups such as the ITEM Coalition (www.itemcoalition.org) and United Spinal Association (www.unitedspinal.org). Encourage involvement in grassroots efforts to effect change on these important issues.

Laura Cohen, PhD, PT, ATP, is a clinical research scientist at the Crawford Research Institute, Shepherd Center, Atlanta, and Barbara Crane, PhD, PT, ATP, is an assistant professor, Physical Therapy Department, University of Hartford, West Hartford, Conn.

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June 2005